WQCSD0762_CS-SSO_20230112

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PAGE 01
Division of Water Resources
5
St t o North Carolina
lDepar•tmentg-f1r' # P� 1 St
Resources
Division of eater Resources
Collection System Sanitary Sewer Overflow Reporting Form
Form CS-SSO
PART is
This form shall be submitted to the appropriate DWR Regional Office within five business days of the first knowledge of the
sanitary sewer overflow (SSO).
Permit Number: _
Facility:
Region: Vn"+ a I -51.1
Source of SSO (check applicable):
(WQCS# if active, otherwise us
Incident #:
City: IV..1` 5G •••1
gd Sanitary Sewer ❑ Pump Station / Lift
SPECIFIC location of the SSO (be consistent in description from past reports or etocu
Station 6, Manhole at Westall & Bragg Street, etc.): O1; �JL1C?VC
Manhole #:
Latitude (degrees/minut
Incident Started Dt:
(mm-dd-yyyy)
Estimated volume of the SSO:
/sec nd):
(hh:mm) AM/PM
ldel0
gallons
Describe how the volume was determined. 9'�v c,�,✓.,�c
Weather conditions during the SSO event: '(1` f . (-lc'-4/
WQCSD#)
Owner: Citexitin .L.Ari S 5-
County: 1,0,
Station
ent tion - i.e. Pu p
Longitude (degrees/mrn to/second):
Incident End Dt: J /1/ / g Time:
(mm-dd-yyyy)
Estimated Duration (round to nearest hour): hour(s)
Did the SSO reach surface waters? ® Yes ❑ No
Volume reaching surface waters: c2-0� gallons
Did the SSO result in a fish kill? ❑ Yes "No ❑ Unknown
if Yes, what is the estimated number of fish killed?
❑ Unknown Th4)
Surface water na ne:
SPECIFIC cause(s) of the SSO:
['Severe Natural Conditions 0 Grease
❑Pump Station Equipment Failure ❑ Power Outa
❑Other (Please explain in Part II)
24- our verbal notification (name of person contacted):
WR ['Emergency Management Date
JAN 12 2023
(hh:mm) AM/PM
/VA1; A)( 4.40
_)Roots El Inflow & Infiltration
ge ❑Vandalism ❑ Debris in line Pipe Failure (Break)
(mm. dd-yyy):
Time: (hh:mm AM/PM):
Per G.S. 143-215.1C(b). the owner or operator of any wastewater collection system s
ball:
In the event of a discharge of 1,000 gallons or more of untreated wastewater to the suface waters of the State. issue
a press release to all print and electronic news media that provide general coverage in the county where the
discharge occurred setting out the details of the discharge. The press release shall be issued within 24 hours after
the owner or operator has determined that the discharge has reached surface waters of the State.
In the event of a discharge of 15,000 gallons or more of untreated wastewater to the surface waters of the State,
publish a notice of the discharge in a newspaper having general circulation in the cou:lty in which the discharge
occurs and in each county downstream from the point of discharge that is significantly affe;ted by the discharge. The
Regional Office shall determine which counties are significantly affected by the discharge and shall approve the form
and content of the notice and the newspapers in which the notice is pubfished.
WHETHER OF NOT PART it IS COMPLETED, A SIGNATURE- iS :REQUIREE SEE PAGE 13
Form CS-SSO page 1

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Pipe Failure (Break)
Pipe size (inches): f
What is the pipe material:
What is the approximate age of the line/ pipe (years old):
Is this a gravity line? [ZYes ❑ No ❑NA ❑ NE
Is this a force main line? ❑ Yes ❑ No DNA ❑ NE
Is the line a "High Priority" line? ❑ Yes ❑ No DNA ❑ NE
Last inspection date and findings:
If a force main then,
Was the break on the force main vertical? ❑ Yes ❑ No DNA ❑ NE
Was the break on the force main horizontal? ❑ Yes ❑ No DNA ❑ NE
Was the leak at the joint due to gasket failure ?
Was the leak at the joint due to split bell?
❑ Yes ❑ No DNA ❑ NE
❑ Yes ❑ No uNA ❑ 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
of the failed section of pipe?
If yes, what measures are taken to control the hydrogen sulfide production?
DNA ❑ NE
When was the line last inspected or videoed?
If line collapsed, what is the condition of the lineup and downstream 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 DNA ❑ NE
If so, then describe
Fonn CS-SSO
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System Visitation
Name:
Certification Number:
Date visited:
Time visited:
ORC
Backup
How was the SSO remediated (Ile. Stopped and cleaned up)?
❑ Yes
❑ Yes
❑ No
❑ No
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:
Signature: `-'1,71,--1..-,/
Telephone Number:
r,L 16)04ov
Date:
Title: rt
) 4.2.62,--3
Any additional information desired to be submitted should be sent to the appropriate Division Regional Office within five
business 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).
Form CS-SSO Pane 13