HomeMy WebLinkAboutWQCS00219_Other Agency Documents_20240226 State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Collection System Sanitary Sewer Overflow Reporting Form
Form CS-SSO
Form CS-SSO Page 1
PART I:
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: ___________________________ (WQCS# if active, otherwise use WQCSD#)
Facility: ______________________________ Incident #: _________________ Owner: ____________________
Region: _____________________________ 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): __________________ Longitude (degrees/minute/second): __________________
Incident Started Dt: _____________ Time: __________ Incident End Dt: _____________ Time: _________________
(mm-dd-yyyy) (hh:mm) AM/PM (mm-dd-yyyy) (hh:mm) AM/PM
Estimated volume of the SSO: _________________ gallons Estimated Duration (round to nearest hour): ____hour(s)
Describe how the volume was determined: ________________________________________________________________
Weather conditions during the SSO event: ________________________________________________________________
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)
24-hour verbal notification (name of person contacted): ______________________________________________________
DWR Emergency Management Date (mm-dd-yyy): __________ Time: (hh:mm AM/PM): ____________
Per G.S. 143-215.1C(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
WQSC00219
Connestee Falls
Western NC
Carolina Water Service of NC
Brevard Transylvania
x
Man Hole # 938 cross country line
000938
35.161700 -82.726183
2/22/24 11:02 am 2/22/24 05:15pm
6
clear
x
Carson Creek
x
x
x
Mara Chamlee left voicemail
2/23/24 09:30 am
Form CS-SSO Page 2
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 3
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: ________________________________________________________________________________________
Form CS-SSO Page 4
Grease (Documentation such as cleaning, inspection, enforcement 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? ____________________________________________
Do you have an enforceable grease ordinance that requires new or retrofit of
grease traps/interceptors? Yes No NA NE
Have there been recent inspection and/or enforcement actions taken on near-
by restaurants or other nonresidential grease contributors? Yes No NA NE
Explain: ___________________________________________________________________________________________
Have there been other SSOs or blockages in this areas that were also caused
by grease Yes No NA NE
When? ____________________________________________________________________________________________
If yes, describe them: ________________________________________________________________________
Have cleaning and inspections ever been done at this location? Yes No NA NE
Explain.
Have educational material about grease been distributed in the past? Yes No NA NE
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? Yes No NA NE
Comments: ________________________________________________________________________________________
Form CS-SSO Page 5
Roots
Do you have an active root control program on the line / area in question? Yes No NA NE
Describe: __________________________________________________________________________________________
Have cleaning and inspections ever been increased at this location because
of roots? Yes No NA NE
Explain: ___________________________________________________________________________________________
What corrective actions have been accomplished at the SSO location (and surrounding system if associated with the SSO)?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
What corrective actions are planned at the SSO location to reduce root intrusion? _________________________________
H
as the line been smoke tested or videoed within the past year? Yes No NA NE
If Yes, when?
__________________________________________________________________________________________________
Comments: ________________________________________________________________________________________
Form CS-SSO Page 6
Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule Yes No NA NE
in any permit that addresses I/I?
Explain if Yes: ______________________________________________________________________________________
What corrective actions have been taken to reduce or eliminate I & I related overflows this spill location
within the last year? __________________________________________________________________________________
Has there been any flow studies to determine I/I problems in the Yes No NA NE
collection system at the SSO location?
If Yes, when was the study completed and what actions did it recommend? ______________________________________
Has the line been smoke tested or videoed within the past year? Yes No NA NE
If Yes, when and what actions are necessary and the status of such actions: _____________________________________
Are there I/I related projects in your Capital Improvement Plan? Yes No NA NE
If Yes, explain: ______________________________________________________________________________________
Have there been any grant or loan applications for I/I reduction projects? Yes No NA NE
If Yes, explain: ______________________________________________________________________________________
Do you suspect any major sources of inflow or cross connections Yes No NA NE
with storm sewers?
If Yes, explain: ______________________________________________________________________________________
Have all lines contacting surface waters in the SSO location and upstream Yes No NA NE
been inspected recently?
If Yes, explain: ______________________________________________________________________________________
What other corrective actions are planned to prevent future I/I related SSOs at this location? ________________________
Comments: ________________________________________________________________________________________
Form CS-SSO Page 7
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) Yes
Audible Yes
Visual Yes
SCADA (two-way communication) Yes
Emergency Contact Signage Yes
Other Yes
If Yes, explain: ______________________________________________________________________________
Describe the equipment that failed: ______________________________________________________________________
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? Yes No NA NE
In no, explain: ______________________________________________________________________________________
If a pump failed, when was the last maintenance and/or inspection performed? ___________________________________
What specifically was checked/maintained? _______________________________________________________________
If a valve failed, when was it last exercised? _______________________________________________________________
Were all pumps set to alternate? Yes No NA NE
Did any pump show above normal run times prior to and during the SSO event? Yes No NA NE
Were adequate spare parts on hand to fix the equipment Yes No NA NE
Was a spare or portable pump immediately available? Yes No NA NE
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: ________________________________________________________________________________________
Form CS-SSO Page 8
Power outage (Documentation of testing, records, tec., should be provided of alternative power source upon
request.)
What is your alternate power or pumping source? __________________________________________________________
Did it function properly? Yes No NA NE
Describe? _________________________________________________________________________________________
When was the alternate power or pumping source last tested under load? _______________________________________
If caused by a weather event, how much advance warning did you have and what actions were taken to prepare for the
event?
__________________________________________________________________________________________________
Comments: ________________________________________________________________________________________
Form CS-SSO Page 9
Vandalism
Provide police report number: __________________________________________________________________________
Was the site secured? Yes No NA NE
If Yes, how? ________________________________________________________________________________________
Have there been previous problems with vandalism at the SSO location? ________________________________________
If Yes, explain: ______________________________________________________________________________________
What security measures have been put in place to prevent similar Yes No NA NE
occurrences in the future?
Comments: ________________________________________________________________________________________
Form CS-SSO Page 10
Debris in line (Rocks, sticks, rags and other items not allowed in the collection system, etc.)
What type of debris has been found in the line? ____________________________________________________________
Suspected cause or source of debris: ____________________________________________________________________
Are manholes in the area secure and intact? Yes No NA NE
When was the area last checked/cleaned? ________________________________________________________________
Have cleaning and inspections ever been increased at this location Yes No NA NE
due to previous problems with debris?
Explain: ___________________________________________________________________________________________
Are appropriate educational materials being developed and distributed Yes No NA NE
to prevent future similar occurrences?
Comments: ________________________________________________________________________________________
Form CS-SSO Page 11
Other (Pictures and police report, as applicable, must be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem? Yes No NA NE
If Yes, explain: _____________________________________________________________________________________
If the problem could not be immediately repaired, what actions Yes No NA NE
were taken to lessen the impact of the SSO?
Comments:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Form CS-SSO Page 12
Pipe Failure (Break)
Pipe size (inches): ________________
What is the pipe material: _____________________
What is the approximate age of the line/ pipe (years old): ___________
Is this a gravity line? Yes No NA NE
Is this a force main line? Yes No NA NE
Is the line a "High Priority" line? Yes No NA NE
Last inspection date and findings: ________________
If a force main then,
Was the break on the force main vertical? Yes No NA NE
Was the break on the force main horizontal? Yes No NA NE
Was the leak at the joint due to gasket failure ? Yes No NA NE
Was the leak at the joint due to split bell? Yes No NA 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 NA NE
of the failed section of pipe?
If yes, what measures are taken to control the hydrogen sulfide production? __________________________
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 NA NE
If so, then describe
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Form CS-SSO Page 13
System Visitation
ORC Yes No
Backup Yes No
Name: __________________________
Certification Number: __________________________
Date visited: __________________________
Time visited: __________________________
How was the SSO remediated (i./e. Stopped and cleaned up)?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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: __________________________
Signature: ______________________________________________ Title: ___________________________________
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).