WQCS00027_DV-2022-DV-2022-0088 Case File_20220815

DIVISION OF WATER RESOURCES - CIVIL PENALTY ASSESSMENT
Violator: Roanoke Rapids Sanitary District
Facility Name: Roanoke Rapids Sanitary Dist Collection System
Permit Number: WQCS00027
County: Halifax
Case Number: DV-2022-0088
ASSESSMENT FACTORS
1) The degree and extent of harm to the natural resources of the State, to the public health, or to private
property resulting from the violation;
12,600 gallons overflowed from a manhole due to inflow, infiltration. All 12,600 gallons flowed to an UT to the Roanoke
River class WS-IV; CA in the Roanoke River Basin. Nutrients and pathogens to surface waters.
2) The duration and gravity of the violation;
The SSO started on 03.24.2022 at 10:00 am and ended the same day at 8:30 pm.
3) The effect on ground or surface water quantity or quality or on air quality;
The effect on surface water quality include increased nutrients and pathogens. Water quality standard violations.
w klc,&
4 The cost of rectifying�` G�`� "itkie
the damage; g ; GJ er bc,svCI 5- ,/ ots
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The costs of rectifying the damage is not given.
5) The amount of money saved by noncompliance;
It is believed that no money was saved by the noncompliance.
6) Whether the violation was committed willfully or intentionally;
It does not appear that the violation was committed willfully or intentionally.
7) The prior record of the violator in complying or failing to comply with programs over which the
Environmental Management Commission has regulatory authority;
There has been 1 enforcement taken during the lastt2 months.
8) The cost to the State of the enforcement procedures.
$36.57
Date
Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ

r.

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
Certified Mail # 7020 3160 0000 4109 6371
Return Receipt Requested
R Danieley Brown, CEO PE
Roanoke Rapids Sanitary District
PO Box 308
Roanoke Rapids, NC 27870
NORTH CAROLINA
Environmental Quality
August 15, 2022
SUBJECT: Notice of Violation and Assessment of Civil Penalty
for Violations of North Carolina General Statute (G.S.) 143-215.1(a)(1)
and Collection System Permit No. WQCS00027
Roanoke Rapids Sanitary District
Roanoke Rapids Sanitary Dist Collection System
Case No. DV-2022-0088
Halifax County
Dear Mr. Brown:
This letter transmits a Notice of Violation and assessment of civil penalty in the amount of $536.57 ($500.00 civil penalty +
$36.57 enforcement costs) against Roanoke Rapids Sanitary District.
This assessment is based upon the following facts: a review has been conducted of the Sanitary Sewer Overflow (SSO)
5-Day Report submitted by Roanoke Rapids Sanitary District. This review has shown the subject facility to be in violation
of the requirements found in Collection System Permit No. WQCS00027 and G.S. 143-215.1(a)(1). The violation(s) that
occurred are summarized in Attachment A to this letter.
Based upon the above facts, I conclude as a matter of law that Roanoke Rapids Sanitary District violated the terms,
conditions or requirements of Collection System Permit No. WQCS00027 and G.S. 143-215.1(a)(1) in the manner and
extent shown in Attachment A. In accordance with the maximums established by G.S. 143-215.6A(a)(2), a civil penalty
may be assessed against any person who violates the terms, conditions or requirements of a permit required by G.S.
143-215.1(a).
North Carolina DeprtmentofEnvironmental Quahly I Division ofWater Resources
Raleigh Regional Ofnce 3800 Barrett Drive i Raleigh North Carolina 27609
919.79t.4200

Based upon the above findings of fact and conclusions of law, and in accordance with authority provided by the
Secretary of the Department of Environmental Quality and the Director of the Division of Water Resources, 1, Scott
Vinson, Regional Supervisor, Raleigh Regional Office hereby make the following civil penalty assessment against
Roanoke Rapids Sanitary District:
$500.00 For 1 of the 1 violations of Collection System Permit No. WQCS00027 and G.S. 143-215.1(a)(1) for
Sanitary Sewer Overflow(s) resulting in a discharge without a valid permit.
$500.00 TOTAL CIVIL PENALTY
$36.57 Enforcement Costs
$536.57 TOTAL AMOUNT DUE
Pursuant to G.S. 143-215.6A(c), in determining the amount of the penalty I have taken into account the Findings of Fact and
Conclusions of Law and the factors set forth at G.S. 143B-282.1(b), which are:
(1) The degree and extent of harm to the natural resources of the State, to the public health, or to private property
resulting from the violation;
(2) The duration and gravity of the violation;
(3) The effect on ground or surface water quantity or quality or on air quality;
(4) The cost of rectifying the damage;
(5) The amount of money saved by noncompliance;
(6) Whether the violation was committed willfully or intentionally;
(7) The prior record of the violator in complying or failing to comply with programs over which the Environmental
Management Commission has regulatory authority; and
(8) The cost to the State of the enforcement procedures.
Within thirty (30) days of receipt of this notice, you must do one of the following:
(1) Submit payment of the penalty, OR
(2) Submit a written request for remission, OR
(3) Submit a written request for an administrative hearing
Option 1: Submit payment of the penalty:
Payment should be made directly to the order of the Department of Environmental Quality (do not include waiver
form). Payment of the penalty will not foreclose further enforcement action for any continuing or new violation(s).
Please submit payment to the attention of:
Attn: PERCS Branch
Division of Water Resources
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

Option 2: Submit a written request for remission or mitigation including a detailed justification for such
request:
Please be aware that a request for remission is limited to consideration of the five factors listed below as they may
relate to the reasonableness of the amount of the civil penalty assessed. Requesting remission is not the proper
procedure for contesting whether the violation(s) occurred or the accuracy of any of the factual statements contained in
the civil penalty assessment document. Because a remission request forecloses the option of an administrative hearing,
such a request must be accompanied by a waiver of your right to an administrative hearing and a stipulation and
agreement that no factual or legal issues are in dispute. Please prepare a detailed statement that establishes why you
believe the civil penalty should be remitted and submit it to the Division of Water Resources at the address listed below.
In determining whether a remission request will be approved, the following factors shall be considered:
(1) whether one or more of the civil penalty assessment factors in NCGS 143B-282.1(b) was wrongfully
applied to the detriment of the petitioner;
(2) whether the violator promptly abated continuing environmental damage resulting from the violation;
(3) whether the violation was inadvertent or a result of an accident;
(4) whether the violator had been assessed civil penalties for any previous violations; or
(5) whether payment of the civil penalty will prevent payment for the remaining necessary remedial actions.
Please note that all evidence presented in support of your request for remission must be submitted in writing. The
Director of the Division of Water Resources will review your evidence and inform you of his decision in the matter of
your remission request. The response will provide details regarding the case status, directions for payment, and
provision for further appeal of the penalty to the Environmental Management Commission's Committee on Civil Penalty
Remissions (Committee). Please be advised that the Committee cannot consider information that was not part of the
original remission request considered by the Director. Therefore, it is very important that you prepare a complete and
thorough statement in support of your request for remission.
In order to request remission, you must complete and submit the enclosed "Request for Remission of civil Penalties,
Waiver of Right to an Administrative Hearing, and Stipulation of Facts" form within thirty (30) days of receipt of this
notice. The Division of Water Resources also requests thatyou complete and submit the enclosed "Justification for
Remission Request."
Both forms should be submitted to the following address:
Attn: PERCS Branch
Division of Water Resources
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
AND
Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
1628 Mail Service Center, Raleigh
Raleigh, NC 27699-1628

Option 3: File a petition for an administrative hearing with the Office of Administrative Hearings:
If you wish to contest any statement in the attached assessment document, you must file a petition for an administrative
hearing. You may obtain the petition form from the Office of Administrative Hearings. You must file the petition with
the Office of Administrative Hearings within thirty (30) days of receipt of this notice. A petition is considered filed
when it is received in the Office of Administrative Hearings during normal office hours. The Office of Administrative
Hearings accepts filings Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m., except for official state
holidays. The petition may be filed by facsimile (fax) or electronic mail by an attached file (with restrictions) - provided
the signed original, one (1) copy and a filing fee (if a filing fee is required by NCGS § 150B-23.2) is received in the
Office of Administrative Hearings within seven (7) business days following the faxed or electronic transmission. You
should contact the Office of Administrative Hearings with all questions regarding the filing fee and/or the details of the
filing process.
The mailing address and telephone and fax numbers for the Office of Administrative Hearings are as follows:
6714 Mail Service Center
Raleigh, NC 27699 6714
Tel: [phone]
Fax: [phone]
One (1) copy of the petition must also be served on DEQ as follows:
Mr, William F. Lane, General Counsel
Department of Environmental Quality
1601 Mail Service Center
Raleigh, North Carolina 27699-1601
Please indicate the case number (as found on page one of this letter) on the petition.
Failure to exercise one of the options above within thirty (30) days of receipt of this letter, as evidenced by an internal
date/time received stamp (not a postmark), will result in this matter being referred to the Attorney General's Office for
collection of the penalty through a civil action. Please be advised that additional penalties may be assessed for violations
that occur after the review period of this assessment.
If you have any questions, please contact Mitchell Hayes with the Division of Water Resources staff of the Raleigh
Regional Office at [phone] or via email at [e-mail].
Sincerely,
Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
ATTACHMENTS
Cc: WQS Raleigh Regional Office - Enforcement File
Laserfiche

E

JUSTIFICATION FOR REMISSION REQUEST
Case Number: DV-2022-0088
Assessed Party: Roanoke Rapids Sanitary District
Permit No.: WQCS00027
County: Halifax
Amount Assessed: $536.57
Please use this form when requesting remission of this civil penalty. You must also complete the "Request For Remission,
Waiver of Right to an Administrative Hearing, and Stipulation of Facts" form to request remission of this civil penalty.
You should attach any documents that you believe support your request and are necessary for the Director to consider in
evaluating your request for remission. Please be aware that a request for remission is limited to consideration of the five
factors listed below as they may relate to the reasonableness of the amount of the civil penalty assessed. Requesting
remission is not the proper procedure for contesting whether the violation(s) occurred or the accuracy of any of the factual
statements contained in the civil penalty assessment document. Pursuant to N.C.G.S. § 143B-282.1(c), remission of a civil
penalty may be granted only when one or more of the following five factors apply. Please check each factor that you
believe applies to your case and provide a detailed explanation, including copies of supporting documents, as to why the
factor applies (attach additional pages as needed).
(a) one or more of the civil penalty assessment factors in N.C.G.S. 143B-282.1(b) were wrongfully applied to the
detriment of the petitioner (the assessment factors are listed in the civil penalty assessment document);
(b) the violator promptly abated continuing environmental damage resulting from the violation (Le., explain the
steps that you took to correct the violation and prevent future occurrences);
(c) the violation was inadvertent or a result of an accident (Le., explain why the violation was unavoidable or
something you could not prevent or prepare for);
(d) the violator had not been assessed civil penalties for any previous violations;
(e) payment of the civil penalty will prevent payment for the remaining necessary remedial actions (Le., explain
how payment of the civil penalty will prevent you from performing the activities necessary to achieve
compliance).
EXPLANATION:

STATE OF NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
COUNTY OF HALIFAX
IN THE MATTER OF ASSESSMENT
OF CIVIL PENALTIES AGAINST
Roanoke Rapids Sanitary District
Roanoke Rapids Sanitary Dist Collection System
PERMIT NO. WQCS00027
WAIVER OF RIGHT TO AN
ADMINISTRATIVE HEARING AND
STIPULATION OF FACTS
CASE NO. DV-2022-0088
Having been assessed civil penalties totaling $536.57 for violation(s) as set forth in the assessment document of the Division
of Water Resources dated August 15, 2022, the undersigned, desiring to seek remission of the civil penalty, does hereby
waive the right to an administrative hearing in the above -stated matter and does stipulate that the facts are as alleged in the
assessment document. The undersigned further understands that all evidence presented in support of remission of this civil
penalty must be submitted to the Director of the Division of Water Resources within thirty (30) days of receipt of the notice
of assessment. No new evidence in support of a remission request will be allowed after (30) days from the receipt of the
notice of assessment.
This the day of , 20
ADDRESS
SIGNATURE
TELEPHONE

ATTACHMENT A
Roanoke Rapids Sanitary District
CASE NUMBER: DV-2022-0088
PERMIT NO: WQCS00027
FACILITY: Roanoke Rapids Sanitary Dist Collection System
Other Violations
REGION: Raleigh
COUNTY: Halifax
INCIDENT VIOLATION
NUMBER DATE VIOLATION TYPE
VIOLATION DESCRIPTION
TOTAL VOLUME PENALTY
(GALLONS) AMOUNT
202200486 3/24/2022 CSO/SSO(Sewer Overflow) Discharge without valid permit
12,600 $500.00

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Total Penalties After Remissions : $2,648.57
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Roanoke Rapids Sanitary District
May 16, 2022
Mr. Scott Vinson, Regional Supervisor
North Carolina Division of Water Resources
1628 Mail Service Center
Raleigh, NC 27699-1628
P.O. Box 30S
1000 Jackson Street
Roanoke Rapids, KC 27870
[phone]
Fax- [phone]
www.rrsd.org
CERTIFIED MAIL: 7005 3110 0001 6339 1343
RETURNED RECEIPT REQUESTED
Re: Notice of Violation
Tracking No.: NOV-2022-DV-0 110
Sanitary Sewer Overflow March 2022
Collection System Permit Number: WQCS00027
Roanoke Rapids Sanitary District Collection System
Halifax County
Dear Mr. Vinson,
Please be advised that ongoing remedial action is being taken to correct the deficiencies in the
collection system contributing to the Sanitary Sewer Overflow in the referenced NOV received May 4,
2022. Please note the incident, as reported in RIMS, required a press release but was below the
threshold for public notice. The SSO, Incident No. 202200486, was located within Sub -Basin 'A' at
manhole A-54.
Freese & Nichols, Inc. completed a flow study to determine III problems in the collection system at the
SSO location on March 4, 2022. Recommended from the study was the option to upsize the Belmont
PS pumping capacity and reroute the force main further downstream: "The recent flow monitoring data
indicate the peak wet weather flows to the Belmont PS occasionally exceed the pumping capacity in the
existing pumps. RRSD has also indicated that during larger wet weather events, when the PS runs
frequently, the downstream gravity sewer becomes surcharged and is at risk for overflows in several
shallow manholes. If the pumping capacity al the PS is increased to handle the peak wet weather flows,
and the force main is rerouted to a larger gravity line further downstream with more capacity, then both
the upstream surcharging and the downstream surcharging would be elim:nated."
Roanoke Rapids Sanitary District submitted an application to the Division of Water Infrastructure for
this project in the Spring 2022 round and expect a response on its funding request later this summer.
Should you require additional information, please do not hesitate to contact us.
Very Truly Yours,
[ram. f
R. t)anie ey Brow P.E.a
Chief Executive fficer
CC: James Kerr, Chairman
Davide W. Scott; File
14OV-2027-Dv-OI10.Responsc220SI6 1'ikee 1 of 1

ROY COOPER
Carernor
ELIZABETH S. BISER
Sanitary
RICHARD E. ROGERS, JR.
Director
Certified Mail # 7020 3160 0000 4192 515Z
11 EN m I at Bea tact
R Danieley Brown, CEO PE
Roanoke Rapids Sanitary District
PO Box 308
Roanoke Rapids, NC 27870
NORTH CAROLINA
Environmental tal Quality
April 19, 2022
SUBJECT: NOTICE OF VIOLATION & INTENT TO ISSUE CIVIL PENALTY
Tracking Na: NOV-2022-DV-0110
Sanitary Sewer Overflows - March 2022
Collection System Permit No. WQCS00027
Roanoke Rapids Sanitary Dist. Collection System
Halifax County
Dear Mr. Brown:
A review has been conducted of the self -reported Sanitary Sewer Overflows (SSO's) 5-Day Report/s submitted by
Roanoke Rapids Sanitary District. The Division's Raleigh Regional Office concludes that the Roanoke Rapids
Sanitary District violated Permit Condition I (2) of Permit No. WQCS00027 by failing to effectively manage,
maintain, and operate their collection system so that there is no SSO (Sanitary Sewer Overflow) to the land or
surface waters and the SSO constituted making an outlet to waters of the State for purposes of G.S.
143-215.1(a)(1), for which a permit is required by G.S. 143-215.1.
The Raleigh Regional Office is providing the Roanoke Rapids Sanitary District an opportunity to provide evidence
and justification as to why the Roanoke Rapids Sanitary District should not be assessed a civil penalty for the
violation(s) that are summarized below:
Inddent Start Duration
Number Date (Mine) Location
Cause
Total Vol
Total Surface
Vol Water
(Gale) (Gals) DWR Action
202200486 3/24/2022 630 Laurel Street Inflow and Infiltration 12,600 12,600 Notice of Violation -
Notloe of Intent
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This Notice of Violation / Notice of Intent to Enforce (NOV/NOI) is being Issued for the noted violation. Pursuant
to G.S. 143-215.6A, a civil penalty of not more than twenty-five thousand dollars ($25,000.00) may be assessed
against any person who violates or falls to act in accordance with the terms, conditions, or requirements of any
permit issued pursuant to G.S.143-215.1.
This office requests that you respond to this Notice, in witting, within 10 business days of its
receipt. In your response, you should address the causes of non-compliance, remedial actions, and all other
actions taken to prevent the recurrence of similar situations. The response to this correspondence will be
considered in this process. Enforcement dedsions will also be based on volume spilled, volume reaching surface
waters, duration and gravity, impacts to public health, Ash kills or recreational area closures. Other factors
considered in determining the amount of the dvil penalty are the violator's history of non-compliance, the cost of
rectifying the damage, whether the spill was intentional and whether money was saved by non-compliance.
If you have any questions, please do not hesitate to contact Mitchell Hayes with the Water Quality Section in
the Raleigh Regional Once at 919-791-4200 or via email at [e-mail].
Sincerely,
Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
Cc: Raleigh Regional Office - WQS File
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R. Danieley Brown, CIE PE
Roanoke Rapids Sanitary District
PO Box 3089
Roanoke Rapids, NC 27870
Roanoke Rapids Sanitary Dist. Collection Syst.
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Roanoke Rapids Sanitary Dist Collection Sys.
NOV-2022-DV.O110 WQCS00027 SV

DWR
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 DWQ Regional Office within five business days of the first knowledge of the
sanitary sewer overflow (SSO).
Permit Number: WQCS00027 (WQCS# if active, otherwise use WQCSD#)
Facility: Roanoke Rapids Sanitary Dist Collection System
Owner: Roanoke Rapids Sanitary District
City: Roanoke Rapids
Source of SSO (check applicable):
County: Halifax
El Sanitary Sewer
Region: Raleigh
Incident #: 202200486
❑ Pump Station / Lift Station
SPECIFIC location of the SSO (be consistent in description from past reports or documentation - i.e. Pump Station 6,
Manhole at Westall & Bragg Street, etc): Laurel Street
Manhole #: 54
Latitude (Decimal Degrees): Longitude (Decimal Degrees):
Incident Started Dt: 03/24/2022 Time: 10:00 am Incident End Dt: 03/24/2022
(mm-dd-yyyy) (hh:mm AM/PM)
Estimated Volume of the SSO: 12,600
(mm-dd-yyyy)
gallons Estimated Duration (Round to nearest hour):
Describe how the volume was determined: visual
Time: 08:30 pm
(hh:mm AM/PM)
10:30 hours
Weather conditions during the SSO event: Heavy Rain
Did SSO reach surface waters? 2 Yes ❑ No ❑ Unknown
Surface water name: ROANOKE RIVER
Volume reaching surface waters (gals): 12600
Did the SSO result in a fish kill? ❑ Yes IZINo ❑ Unknown
SPECIFIC cause(s) of the SSO:
E0 Inflow and Infiltration
24 hour verbal notification (name of person contacted ):
If Yes, what is the estimated number of fish killed? 0
Dorothy M Robson
DWR ❑ Emergency Mgmt Date (mm-dd-yyy): 03/25/2022 Time (hh:mm AM/PM): 09:25:00 am
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 24-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 reauired 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
WHETHER OR NOT PART III IS COMPLETED. A SIGNATURE IS REQUIRED AT THE END OF THIS FORM
CS-SSO Form
Page: 1

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
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in any ❑ Yes RI No ❑ NA ❑ NE
permit that addresses Ill?
Explain if Yes:
What corrective actions have been taken to reduce or eliminate I & I related overflow
at this spill location within the last year?
Flow Study in 2021 upstream from manhole 54.
Has there been any flow studies to determine I/1 problems in the collection system at WI Yes ❑ No ❑ NA ❑ NE
the SSO location?
If Yes, when was the study completed and what actions did it recommend?
The district is working on a PER and looking into relocating the force main.
Has the line been smoke tested or videoed within the past year? ❑ Yes 171 No ❑ NA ❑ NE
If Yes, when and indicate what actions are necessary and the status of such actions:
Are there I/1 related projects in your Capital Improvement Plan? ❑ Yes ❑ No 171 NA ❑ NE
If Yes, explain:
Have there been any grant or loan applications for Ill reduction projects? ❑ Yes WI No ❑ NA ❑ NE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections with storm sewers; WI Yes ❑ No ❑ NA ❑ NE
If Yes, explain:
RRSD have done multiple study in basin A over the years with new services replaced and new cured in place liners instal
over the last few years.
Have all lines contacting surface waters in the SSO location and upstream been 17 Yes ❑ No ❑ NA ❑ NE
inspected recently?
If Yes, explain:
The main sewer line up stream was cleaned for maintenance on 3/8/2022 for 1500 feet.
CS-SSO Form Page: 2

What other corrective actions are planned to prevent future I/I related SSOs at this
location?
At this time we are still looking into the matter of our force main, with possible smoke testing up stream of the spill locatio►
Comments:
System Visitation
ORC 171 Yes
Backup ❑ Yes
Name:
David W. Scott
Cert#
999152
Date visited:
03/24/2022
Time visited:
10:00 AM
How was the SSO remediated (i.e. Stopped and cleaned up)?
M/H 54 stopped running over around
8:30 PM and the spill location was cleaned and lime was put down around this location.
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: David W Scott Date: 03/29/22 08:23 am
Signature: Title:
Telephone Number:
Any addition information desired to be submitted should be sent to the appropriate Division Regional Office within five days of 1
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of th
form is completed, if used).
CS-SSO Form Page: 3