NC0021849_Report_20231222

State of North Carolina
Department of Environment and Natural Resources
DWR Division of Water Resources
Collection System Sanitary Sewer Overflow Reporting Form
Division of Water Resources Form CS-SSO
PART 1:
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). q
Permit Number: /UC Qu a i y 1 (WQCS# if active, otherwise use WQCSD#)
Facility: JGAV\ o� k1-t �1-�rA Incident #: �9O 3 016 10 Owner: 7��
Region: I.IaI City: County:
Source of SSO (check applicable): ❑ Sanitary Sewer ❑ 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.):
Manhole #:
Latitude (degrees/minute/second): _
Incident Started Dt: o? 17 N27_
(mm-dd-yyyy)
Estimated volume of the SSO:
Time: lI: UV
(hh:mm) AN6M
gallons
Longitude (degrees/minute/second): _
Incident End Dt: Time
o?"aU
(mm-dd-yyyy) (hh:mm) AM/�p
Estimated Duration (round to nearest hour): /S hour(s)
Describe how the volume was determined:
Weather conditions during the SSO event: Oecw / Ac--�
Did the SSO reach surface waters? ❑ Yes ❑ No ❑ Unknown
Volume reaching surface waters: gallons Surface water name:
Did the SSO result in a fish kill? ❑ Yes ❑ 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
❑Pump Station Equipment Failure ❑ Power Outage ❑Vandalism ❑ Debris in line ❑Pipe Failure (Break)
❑Other (Please explain in Part II) c
24-hour verbal notification (name of person contacted): S��- �%� n sa-n
�WR ❑Emergency Management Date (mm-dd-yyy): Time: (hh:mm Af P( :
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 t

In order to submit a claim for justification of an SSO, you must use Part II of form CS-SSO with additional documentation as
necessary. DWR staff will review the justification claim and determine if enforcement action is appropriate.
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 2

Severe Natural Conditions (hurricane, tornado, 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: r'it -A :s �ho�,'i'r dam" �y L �t l%v� /Ja..�� Oe 6!"t {S14
U hs s 4J, e-
vW -H,
$�t -�,., err �✓rrc crh�2,'rJ a.nJ
Fonn CS-SSO Page 3

System Visitation
ORC
Backup
Name: Ttte-' WN 4C1e St,
Certification Number: 10 1 1 J 3 J
Date visited: Pa )III N23
Time visited: D• o c) AM
How was the SSO remediated (ide. Stopped and cleaned up)?
Yes ❑ No
❑ Yes ❑ No
(f� M :rLcws Mj y--f end, 7!e .g/. S'cq{ Ad' .14Z M lw
al,� A ��3 i.a��m�'"s k �'la,,r�+r5 .lrr cC�l4•,-t.� �,ti'f
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:
Date: 1219 21 ,2023
Signature: Title: COAI'►VLJ/ 61- 0 9C
Telephone Number: arj a-�irJS- i a'aS
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).
Fonn CS-SSO Page 13