WQCS00370_3121_0001_SSO Report_20221116

Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART I
This form shall be submitted to the appropriate DWQ Regional Office within five days of the first knowledge of
the sanitary sewer overflow (SSO).
Permit Number
Facility:
Owner:
City:
(WQCS# if active, otherwise use treatment plant NCIWQ#)
T—,,w„�a5k b j
j r tauc5
Source of SSO (check applicable) :
Sanitary Sewer
® Pump Station
Incident #
Region:
County: &2€47 '1
SPECIFIC location of the SSO (be consistent in descrip ron from past repo or cycumentation - i.e. PJmp Sitphir 6,
Manhole at Westall & Bragg Street, etc.) :
Latitude (degrees/minutelsecond): Longitude(degrees/minute/second)•
!
}y 0 Time G� a Ca Incident End Dt: Timer---------
i fa Gi
hh:mm AWPM (mm-dd-yyyy) w hh:mm AM/PM
0,,
Incident Started Dt:
(mm-dd-yyYY)
Estimated volume of the SSO: z v.CO gallons Estimated Duration (Round to nearest hour):
° dc�l' -1 t c��.�ll -/h -e Eve
Describe how the volume was determined: Weather conditions during SSO event: 17o e""5' Ai -
Did SSO reach surface waters? 0 Yes KIhio 0 Unknown Volume reaching surface waters (gallons):
Surface water narne:
Did the SSO result in a fish kill? ❑ Yes IZ o a Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cau (s) of the SSO:
Severe Natural Condition ❑ Grease
0 Roots
Ei Inflow and Infiltration El Pump Station Equipment Failure ❑ Power outage
0 Vandalism ID Debris in ,ne El Other (Please explain in Part 11)
��-
J:oft-} t 6.%.t4'c/-
,immediate 24-hour verbal notification reported to:
I �l OWQ EJ Emergency Mgmt. Date (mm-id-yyyy):
Time (hh:mm AM/PM): 2:.- o0' f
if an SSO is ongoing, please notify Regional Office on a daily basis until SSO can be stopped.
wastewater to surface
et G.S. issue
1C(b), the responsible
48-hours of fiof a rst knowledge to all print and electronic untreatede of 1,000 gallons or more of ews media providing general
waters shall issue au press release
coverage in the county where the discharge occurred- When 15,000 gallons or more of untreated wastewater
atew t r enters
sion within 30 days.
surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided
Refer to the referenced statute for further detail.
The Director, Division of Water Quality, may take enforcement action for SSOs that are required to be reported to Division unless it
is demonstrated that:
1) the discharge was caused by severe natural conditions and there were no feasible alternatives 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 11 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.
WHETHER OR NOT PART 11 1S COMPLETED, A SIGNATURE IS REQUIRED AT THE END OF THIS FORM.
Page
CS-SSO Form October 9, 20Q3

Form CS-SSO
Collection System Sanitary Sewer Overflow Reporting Form
PART I I
ANSWER THE FOLLOWING QUESTIONS FOR EACH RELATED CAUSE CHECKED IN PART l OF THIS FORM
AND INCLUDE THE APPROPRIATE DOCUMENTATION AS REQUIRED OR DESIRED
COMPLETE ONLY THOSE SECTIONS 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 DWQ REGIONAL OFFICE
UNLESS IT HAS BEEN SUBMITTED ELECTRONICALLY THROUGH THE ONLINE REPORTING SYSTEM___
Severe Natural Condition (hurricane, tornado, etc.)
Describe the "severe natural condition" in detail
c/
I�,45 0%4I i.4+1 Pi J S` tie-(-a�+..% iI-eh
How much advance warning did you have and what actions were taken in preparation for the event?
V7
Comments:
c
Gfi / trav4% L v C lec-kgesa ,Lt
In e-1 w'h LI Qv'C. IM . 5'1,4- orcem nt
Grk (Documentation suer as gearing, inspections,
at
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?
pvc€o.0a hail" e t yr
e 19if 1 et
2 31.2F Z04.4 T'jo
Do you have an enforceable grease ordinance that requires new or retrofit of grease traps/interceptors?
Have there been recent inspections and/or enforcement actions taken on nearby restaurants or other
nonresidential grease contributors?
Explain.
4 VI
LYesi.-1 No ®NA D NE
YesE3 No LJ NA ONE
Have there been other SSOs or blockages in this area that were also caused by grease?
When?
If yes, describe them:
0Yesl NoNADNE
Have leaning and inspections ever been increased at this location?
Explain.
❑ Yefl No ICJ NA LANE
CS-SSO Form October 9, 2003
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Have educational materials about grease been distributed in the past?
When?
and to whom?
Explain?
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:
❑ Yegl No 0 NA Q NE
DYefl No NA 6 NE
Roots
❑Ye Na®NAL-...ENE
Do you have an active root control program?
Describe
(AA/ d'V
e 5
Have cleaning and inspections ever been increased at this location because of roots?
❑Yeo®NA®NE
Explain:
What corrective actions have been accomplished at the SSO location (and surrounding system if
associ,at d ith the SSO):
1 • + . �; / v er'eis
What corrective actions are planned at the SSO location to reduce root intrusion? �,.a.
Has the line been smoke tested or videoed within the past year?
It Yes, when?
EICID No ®NA ONE
Comments:
yak .t 41 /4CV Y!
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule in any permit that
addresses If1?
CSSSO Form October 9, 200
cog Cp; i 4
-/h4 U SOP f v
DYesEJ No0NA0NE
5°ems
Page

Explain if Yes:
What corrective actions have been taken to reduce or eliminate I & 1 related overflows at this spill location
within the last year? rt4- vast/
Has there been any flow studies to determine Ili problems in the collection system at the SSO location? 12 YesO No DNA ONE
If Yes, when was the study completed and what actions did it recommend?
Has the line been stroke tested or videoed within the past year?
If Yes, when and indicate what actions are necessary and the status of such actions:
Are there III related projects in your Capital Improvement Plan?
if Yes, explain:
Have there been any grant or loan applications for III reduction projects.
rL1 esD No DNA ONE
DYe NaDNADNE
year 2--a ff �l
e b No DNA D NE
If Yes, explain:
'4 ! -� -1q 1C+ ,� i b4.4 yirt 00( Cf., ICI
Do you suspect any major sources of inflow or cross connections with storm sewers? 0 Yed�1 No E� NA NE
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream been inspected recently?
❑YesO No NA 0 NE
if Yes, explain:
What other corrective actions are planned to prevent future lit related SSOs at this location?
ie. It -
Comments:
4.1
twerml
tat
Pump Station Equipment Failure (Documentation of testing, records etc_,_
shoul be provided upon request.)
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one-way communication)
t Yes
CS-SSO Form October 9, 2003
Page 4

t�JYes
Audible
l� Yes
Visual
SCADA (two-way communication)
❑ Yes fa C
Emergency Contact Signage ®Yes
l�
Other Yes
Describe the equipment that failed?
eiol
What Kind of situations trigger an alarm condition at this station (Le, pump failure power failure, high171
uiP >r A/C f4
1411Yes0 No0NA0NE
water, etc.)?
Were notification/alarm systems operable?
If no, explain:
If a pump failed, when was the last maintenance and/or inspection performed?
i
What specifically was checked/maintained?
If a valve failed, when was it last exercised?
Were all pumps set to alternate?
Did any pump show above normal run times prior to and during the SSC) event?
Were adequate spare parts on hand to fix the equipment (switch, fuse, valve, seal, etc.)?
Was a spare or portable pump immediately available?
if a float problem, when were the floats last tested? How?
Zej
If an auto -dialer or SCADA, when was the system last tested? Ho ?
UYesEl No 0 NA D NE
Yes0 No 0 NA 0 NE
YeJD No NA NE
L iy:E1 No0NA0NE
comments:
CS SSO Form October 9, 2003
Page 5

Power outage (Documentation of testing, records, etc., should be
provided of alternative power source upon request)
What is your alternate power or pumping source?
Did it function properly?
Describe?
When was the alternate power or pumping source last tested under load?
ek
1.2 iYi/elJ NoDNAONE
If caused by a weather event, how nuch advance warning lid you have and what actions were taken( to /
prepare for the evL 1 .di rx�,.i rr,11+
Comments: "Prise + vf! etl)ne,.-,a eigel 0,91 „dotplo ,%ra Fy
Vandalism
ei a
Provide police report number. Was the site secured? ®Yes® No DNA ONE
It Yes, how?
Have there been previous problems with vandalism at the SSC location?
If Yes, explain:
What security measures have been put in place to prevent similar occurrences in the future?
Comments:
„aid
Y
: 1 No0NAONE
QYeE No ®NA ONE
Debris in line (Rocks, sticks, rags and other items not allowed in the
collection system, etc.)
What type of debris has be n f and in the line?
How could it have gotten there?
Are manholes in the area secure and intact?
CS•SSO Form Octhher 9, 2003
eyez No 0 NA 0 NE
Page 5

When was the area last checked/cleaned?
7- A. r9b'
Have cleaning and inspections ever been increased at this location due to previous problems with debris? OYes1 No ®NA ❑ NE
Explain:
Are appropriate educational materials being developed and distributed to prevent future similar Y s0 No 0 NA 0 NE
occurrences?
Comments:
Other (Pictures and a police report should be available upon request)
Describe:
Were adequate equipment and resources available to fix the problem?
i.Y_:sr] No0NAONE
If Yes, explain:
1/1 4.,.E hod 4 d. A- O .fr A71-m
If the problem could not be immediately repaired, what actions were taken to lessen the impact of the
SSO?
Comments:
For DWQ Use Only:
DWQ Requested an Additional Written Report:
If Yes, What Additional Information is Needed:
Comments:
re r
CS-SSO Form October 9, 2003
❑YesD No DNAEINE
Page 7

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: Rye F r-142
Signature:
Telephone Number:
Date: Zi4je"
Title* filb k er43 )el"kC o, K,
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).
CS-SSO Form
October 9, 2003
Page 8