WQCS00191_SSO_5-Day_202201804_20221230_20221230

IN D_e,partment of
State of N4Fii/aftlii�?Ital Quality
Department of Environment and Natural ResoRMlved
Division of Water Resources
W-1vislon
JAN 0 3 2023��Collection System Sanitary Sewer Overflow Reporting Form
'Dof Water Resources F6rmWFn§F6h-Salem
PART I: Regional Office
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: WQ 5 �I9!I (WQCS# if active, otherwise use WQCSD#)
Facility: ID �y,1 4 WIn-A-641, l.a�IEci�+n�5/sir+ Incident#: �O i� 1�9it�t-i Owner: Tf7v)n of i�Ju(/l,li- ��
Region: W �mrl-n 65ICm City: Wd1AA Co✓¢, County: ,SfokeS
Source of SSO (check applicable): ❑ SanitarySewer 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.): hln�,J � CcuP_ -lee".G, C {,e
- — -Manhole #:- -- --- - - - - — — - - - — -- - - - - - - - -- - - -- - -- - -
Latitude (degrees/minute/seco d): ll Longitude (degrees! inute/second):
Incident Started Dt: Ia ? `aOja Time: I a� Incident End Dt: I , ad Time: 3—pvyi
(mm-dd-yyyy) (hh:mm) AM/PM (mm-dd-yyyy) (hh:mm) AM/PM
Estimated volume of the SSO: . co gallons Estimated Duration (round to nearest hour): 3 hour(s)
Describe how the volume was determined: E •{-Taw};o •t D^ �50 AyLA)
Weather conditions during the SSO event: Gold Q/ J Clear SIc ieS
Did the SSO reach surface waters? Yes ❑ No ❑ Unknown i �IS �re�IC
Volume reaching surface waters: 5� gallons Surface water name:
Did the SSO result in a fish kill? ❑ Yes [9'No ❑ Unknown
If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
❑Severe Natural Conditions ❑ Grease ❑Roots ❑Inflow & Infiltration
Dump Station Equipment Failure ❑ Power Outage ❑Vandalism ❑ Debris in line ❑Pipe Failure (Break)
❑Other (Please explain in Part II)
24R hourverbal notification (name of person contacted): Or'• 6LD(le-
Pj D-hWR ❑Emergency Management Date (mm-dd-yyy): /° Time: (hh:mm AM/PM): /, - -
Per G.S. 143-215.1 C(b), the owner or operator of any wastewater collection system shall:
In the event of a discharge of 1,000 gallons or more of untreated wastewater to the surface 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 county in which the discharge
occurs and in each county downstream from the point of discharge that is significantly affected 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 published.
WHETHER OF NOT PART II IS COMPLETED, A SIGNATURE IS REQUIRED SEE PAGE 13
Form CS-SSO Page 1

Pump Station Equipment Failure (Documentation of testing records, etc should be provided upon request
What kind of notification/alarm systems are present?
Auto-dialer/telemetry (one-way communication)
EI Yes
Audible
u Yes
Visual
[ Yes
SCADA (two-way communication)
❑ Yes _ _... .
Emergency Contact Signage
Yes
Other
❑ Yes
If Yes, explain:
Describe the -equipment that failed: 60�� S ewp�� CJMpS - V&« ()o tv � w^ C_Tbna • - - - - "
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? 16 Yes ❑ No ❑NA ❑ NE
In no, explain:
If a pump failed, when was the last maintenance and/or inspection performed?
7'5 PI
What specifically was checked/maintained? _(G� VIIIP 0PL/ ;0,j / U tJV�` iAS�ft ^ V{ L
If a valve failed, when was it last exercised?
Were all pumps set to alternate?
❑ Yes u No ❑NA ❑ NE
Did any pump show above normal run times prior to and during the SSO event? ❑ Yes [2f No
Were adequate spare parts on hand to fix the equipment
Was a spare or portable pump immediately available?
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:
❑ Yes u No
❑ Yes [y No
❑NA ❑ NE
❑NA ❑ NE
❑NA ❑ NE
Form CS-SSO Page 7

System Visitation
Name:
Certification Number:
Date visited:
Time visited:
ORc cKso� W, Ilard
Backup MetpK 60ijMA-r)
W; L g(,,-a►ey
Ta�lcsC�n l 1, [ILI
l01 a01�1
8-3o erg 9.'1SRin
How was the SSO remediated (i.le. Stopped and cleaned up)?
OVIC Groind jartQ �' WG5 con4-6,,a g/I 42d-
V Yes
19 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. • / r �/'�
Person submitting claim: 136cl<jJ/t VV 6�Itf«` Date: I �/ 5LO
Signature: Title: '//�' (��I�eGi U^S C/ R
Telephone Number:
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
Page 13