WQCSD0750_Incident 202200791 5-day report_20220529

D R
Division of Water Resources
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Collection System Sanitary Sewer Overflow Reporting Form
Form CS-SSO
PART I:
This form shall be submitted to the appropriate DWR Regional Office within five days of the first knowledge of the sanitary
sewer overflow (SSO). ,[
Permit Number. (WQCS# If active, otherwise use WQCSD#) la/Q Gf p 0 7'5C/�'
Facility: Pnte Mori (e Wm-&rk WIMP Incident#:241100191 Owner: r0.»41,0,^
Region: ito,bi51, City: Ara, .r(AJ9e County: Tokricre✓) CAunj-j
Source of SSO (check applicable): ❑ Sanitary Sewer 0 Pump Station / Lift Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation -1i�.e. Pump
Station 6, Manhole at Westall & Bragg Street, etc.): f- It3 Pate, 'A , le, iioMc fori< Wr ' P
Manhole#: N/A SC*42'36"P/ 8"22:0"W lo?
Latitude (degrees/minute/second): Longitude (degrees/minute/second):
Incident Started Dt:OC-251o22 Time: t 2 . o o Incident End Dt: o f -1 V- Zo21 Time: D sr bo
(mm-dd-yyyy) (hh:mm)®UPM (mm-dd-yyyy) (hh:mm) AM/150
Estimated volume of the SSO: (6fj gallons Estimated Duration (round to nearest hour): 11- hour(s)
Describe how the volume was determined: Flow ralol'7.eretch. ' Fi s-o4- (;-bsi'', n*+ rebAiris corree('iy
it d{iNto.+el -to lie_ lass-/ X10-f ow (21 eJ ape -tyro/ e4MQY.
Weather conditions during the SSO event: i✓(ea(
Did the SSO reach surface waters? Q Yes ❑ No 0 Unknown
tJn•.awe.d rs
Volume reaching surface waters: 160 gallons Surface water name: fnLou1' of Qu#nto Creek
Did the SSO result In a fish kill? 0 Yes Er No ❑ Unknown
If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
['Severe Natural Conditions Q Grease ['Roots ['Inflow & Infiltration
❑Pump Station Equipment Failure ❑ Power Outage ['Vandalism ❑ Debris in line ❑Pipe Failure
(Break)
❑Other (Please explain in Part II) Mi -I 1 f1c.y9e
24-hour verbal notification (name of person contacted):
❑DWR ['Emergency Management Date (mm-dd-yyy): Time: (hh:mm9!PM): pcj:QQ
If an SSO is ongoing, please notify the appropriate Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1C(b), the responsible party of a discharge of 1,000 or more of untreated wastewater to surface
waters shall Issue a press release within 48-hours of first knowledge to all print and electronic news media providing
general coverage In the county where the discharge occurred. When 15,000 gallons or more of untreated
wastewater enters surface waters, a public notice shall be published within 10 days and proof of publication shall be
provided to the Division within 30 days. Refer to the reference statute for further detail.
The Director, Division of Water Resources, may take enforcement action for SSOs that are required to be reported to
Division unless it is demonstrated that:
1) the discharge was cause by sever natural conditions and there were no feasible alternative to the discharge; or
2) the discharge was exceptional, unintentional, temporary and caused by factors beyond the reasonable control of
the Permittee and/or owner, and the discharge could not have been prevented by the exercise of reasonable control.
Part II must be completed to provide a justification claim for either of the above situations. This information will be the
basis for the determination of any enforcement action. Therefore, it is important to be as complete as possible
Form CS-SSO Page 1

I1WR
Division of Water Resources
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Collection System Sanitary Sewer Overflow Reporting Form
Form CS-SSO
WHETHER OF NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED SEE PAGE 13
Form CS-SSO
Page 2

PART II:
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART I OF THIS FORM AND
INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTONS PERTAINING TO THE CAUSE OF THE SSO AS CHECKED IN PART I
(In the check boxes below, NA = Not Applicable and NE = Not Evaluated)
A HARDCOPY OF THIS FORM SHOULD BE SUBMITTED TO THE APPROPRIATE DWR REGIONAL OFFICE UNLESS
IS HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM
Form CS-SSO
Page 3

Severe Natural Conditions (hurricane,tomado, etc
Describe the 'severe natural condition' in detail:
How much advance warning did you have and what actions were taken in preparation for the event?
Comments:
Form CS-SSO
Page 4

Grease Documentation such as cleaning inspection, enforcement actions. past overflow reports educational
material and distribution date, etc. should be available upon request.)
When was the last time this specific line (or wet well) was cleaned? tJ hVG1.01A/1
Do you have an enforceable grease ordinance that requires new or retrofit of
grease traps/Interceptors? ❑ Yes 12I No ❑ NA ❑ NE
Have there been recent Inspection and/or enforcement actions taken on near-
by restaurants or other nonresidential grease contributors? ❑ Yes © No DNA 0 NE
Explain: UNkv‘DWr
Have there been other SSOs or blockages in this areas that were also caused
by grease ❑ Yes 0 No DNA ❑ NE
When?
If yes, describe them:
Have cleaning and inspections ever been done at this location? IrJ Yes E No DNA ❑ NE
Explain.
1.r .4r-e-e-i(io►, fD look -Ca teur-ce of diIoriv -. cfean;..y chen+r,.„ly 4., zef,c.€i+.
Have educational material about grease been distributed In the past? ❑ Yes 0 No DNA ❑ NE
When:
and to whom:
Explain: U. ky o vies
If the SSO occurred at a pump station, when was the wet well and pumps last checked
for grease accumulation:
Were the floats clean?
Comments:
very Sra 9h,,,:4y-•resyr-1,.
❑ Yes ❑ No QNA ❑ NE
Form CS-SSO
Page 5

Roots
Do you have an active root control program on the lino / area In question?
Describe:
Have cleaning and Inspections ever been Increased at this location because
of roots?
Explain:
❑ Yos
❑ Yes
What corrective actions have been accomplished at the SSO location (end
surrounding system if associated with the SSO)7
What corrective actions are planned at the SSO location to reduce root Intrusion?
❑yes No
Has the line been smoke tested or videoed within the past year?
If Yes, when?
Comments:
Form CS-SSO
[i No
No
❑NA ❑ NE
❑NA ❑ NE
ENA
❑ NE
Page 6

Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule ❑ Yes Q No ❑NA ❑ NE
in any permit that addresses Ill?
Explain if Yes:
What corrective actions have been taken to reduce or eliminate I & i related overflows this spill location
within the last year?
Has there been any flow studies to determine I/1 problems In the ❑ Yes 121 No ❑NA El NE
collection system at the SSO location?
If Yes, when was the study completed and what actions did It recommend?
Has the line been smoke tested or videoed within the past year?
❑ NE
If Yes, when and what actions are necessary and the status of such actions:
Are there I/1 related projects in your Capital Improvement Plan?
❑ NE
If Yes, explain:
Have there been any grant or loan applications for I/1 reduction projects?
❑ NE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections
❑ NE
with storm sewers?
If Yes, explain: ) .1g,
poS5;1a1� Cruit cornet .ors. very Ik (
Have all lines contacting surface waters in the SSO location and upstream
❑ NE
been inspected recently?
If Yes, explain:
❑ Yes No ❑NA
❑ Yes El No DNA
❑ Yes No ❑NA
Q Yes ❑ No ❑NA
❑ Yes
What other corrective actions are planned to prevent future I/1 related SSOs at this location?
Comments:
2 No ❑NA
pwish-1Lay, e rFct LA.J;Fk IJ& tt) i9 o-✓arLao(e +to ke.-es
Form CS-SSO Page 7

Pump Station Equipment Failure (Documentation of testing records etc should be provided upon re uest
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one-way communication) ❑ Yes
Audible 0 Yes
Visual ❑ Yes
SCADA (two-way communication) ❑ Yes
Emergency Contact SIgnage ❑ Yes
Other ❑ Yes
If Yes, explain: ki
rfor e--• T,E. ;$ ° ft,/ Small fiSiei,.,. C: lO rW»w I10lej an 2 5hree4%
Describe the equipment that failed: G(e<fe. G(o59 e d .tom ; „ch„eA+ l ne. 42. tile (Ai WTI'
What kind of situations trigger an alarm condition at this station (i.e. pump failure, power failure, high water, etc.)?
Were notification/alarm systems operable? ❑ Yes LJ No ❑NA ❑ NE
In no, explain: Kp o�larw►S
If a pump failed, when was the last maintenance and/or Inspection performed?
What specifically was checked/malntalned?
If a valve failed, when was it last exercised?
Were all pumps set to alternate?
❑ NE
❑ Yes
Did any pump show above normal run times prior to and during the SSO event? ❑ Yes
❑ NE
Were adequate spare parts on hand to fix the equipment ❑ Yes
❑ NE
Was a spare or portable pump immediately available? ❑ Yes
❑ NE
If a float problem, when were the floats last tested? How?
If an auto -dialer or SCADA, when was the system last tested? How?
Comments:
Form CS-SSO
❑ No 0NA
❑ No ©NA
❑ No ❑NA
❑ No ❑NA
Pagc 8

Power outage (Documentation or testing, records, tec., should be provided of alternative power source upon
re uest.
What Is your altemate power or pumping source?
Did It function properly?
Describe?
When was the altemate power or pumping source last tested under Toad?
If caused by a weather event, how much advance waming did you have and what actions were taken to prepare for the
event?
Comments:
❑ Yes ❑ No QNA ❑ NE
Form CS-SSO
Page 9

Vandalism
Provide police report number.
Was the site secured?
❑ NE
If Yes, how?
Have there been previous problems with vandalism al the SSO location?
If Yes, explain:
What security measures have been put in place to prevent similar
❑ NE
occurrences in the future?
Comments:
Form CS-SSO
0 Yes
❑ Yes
No EiNA
El No E NA
Page 10

What type of debris has been found In the line?
Suspected cause or source of debris:
Debris In line (Rocks, sticks, rags and other items not allowed in the collection system, etc.).
G�Qf�
Are manholes in the area secure and intact? [Yes ❑ No ❑NA
❑ NE
When was the area last checked/cleaned?
'�hCtrowv+
Have cleaning and inspections over been increased al this location (1'4s ❑ No DNA
❑ NE
due to previous problems with debris? 00
Explain: C�`/©(� d- cit, .,„y Sdv red._
Are appropriate educational materials being developed and distributed
❑ NE
to prevent future similar occurrences? 1,)A6 tJf1
Comments:
Form CS-SSO
❑ Yes
❑ No DNA
Page I I

Form m CS-sSO Pagc 12

Other (Pictures and police report, as applicable, must be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem?
❑ NE
If Yes, explain:
Yes
❑ No DNA
96ck)e J ►-J 04 -r1 1-44- /' i -6,AL
If the problem could not be immediately repaired, what actions
❑ NE
were taken to lessen the Impact of the SSO?
Comments:
❑ Yos El No DNA
Form CS-SSO
Pagc 13

Pipe Failure (Break)
Pipe size (inches)
What is the pipe material
What Is the approximate age of the line! pipe (years old)
Is this a gravity line? ❑ Yes ❑ No UNA
❑ NE
Is this a force main line? ❑ Yes ❑ No [ NA
❑ NE
Is the line a "High Priority" line? ❑ Yes ❑ No ❑NA ❑ NE
Last Inspection date and findings
If a force main then,
Was the break on the force main vertical? ❑ Yes ❑ No ❑NA
❑ NE
Was the break on the force main horizontal? ❑ Yes ❑ No [NA
❑ NE
Was the leak at the joint due to gasket failure ?
Was the leak at the joint due to split bell?
❑ Yes ❑ No ©NA ❑ NE
❑ Yes ❑ No QINA ❑ NE
When was the last inspection or test of the nearest air -release valve to determine if operable?
When was the last maintenance of the air release performed?
If gravity sewer then,
Does the line receive flow from a force main immediately upstream ❑ Yes ❑ No ❑NA
❑ NE
of the failed section of pipe?
If yes, what measures are taken to control the hydrogen sulfide production?
When was the line last inspected or videoed?
If line collapsed, what is the condition of the line up and down stream of the failure?
What type of repair was made?
If temporary, when is the permanent repair planned?
Have there been other failures of this line in the past five years? ❑ Yes ❑ No ©NA ❑ NE
If so, then describe
Form CS-SSO Page 14

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Itx.
Form CS-SSO
Page 15

System Visitation
ORC WW'4
Backup
Name: D. t L+k c*ii ey
Certification Number. cigE3 �8
Date visited: _ 2 S L022 (v i,
Time visited: OCf*.CO 1M
How was the SSO remedlated Ode. Stopped and cleaned up)?
2 Yes
❑ Yes
As a representative for the responsible party. I certify that the Information contained In this report Is true and accurate to the
best of my knowledge.
Person submitting claim: 3). Ma h e.ul Ba.TikeY
Date: d r- 2$ - 20 22
Telephone Number. gi9-415--16V6
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five
days of first knowledge of the SSO with reference to the incident number (the incident number is only generated when
electronic entry of this form is completed, if used).
Fenn CS -SSO
Pagc 16