WQCS00005_NOV-2024-DV-0256_20240717

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WATER MANAGEMENT
CITY OF DURHAM
City of Durham
Department of Water Management
1600 Mist Lake Drive
Durham, NC 27704
919-560-4344
July 16, 2024
Ms. Vanessa Manuel, Assistant Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
NCDEQ, Division of Water Resources
3800 Barrett Drive
Raleigh, NC 27609
Subject: Response to NOV-2024-DV-0256
Dated: June 7, 2024; Received: June 26, 2024
Permit No. WQC500005
SCANNED
NC Per
JUL 17 2024
On Tuesday, July 16, 2024, 1 received the document and attachments addressed to:
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Received

WATER MANAGEMENT
CITY OF DURHAM
City of Durham
Department of Water Management
1600 Mist Lake Drive
Durham, NC 27704
919-560-4344
July 17, 2024
Ms. Vanessa Manuel, Assistant Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
NCDEQ, Division of Water Resources
3800 Barrett Drive
Raleigh, NC 27609
Subject: Response to NOV-2024-DV-0256
Dated: June 7, 2024; Received: June 26, 2024
Permit No. WQCS00005
Dear Ms. Manuel,
Please permit this letter to respond to the above referenced Notice of Violation & Intent to
Issue Civil Penalty received on June 26, 2024. As graciously requested in the letter, the
following evidence and justification demonstrates that these events were exceptional,
unintentional, temporary, and beyond reasonable control of the utility. This evidence will also
establish the significant costs and actions taken to stop the discharge; contain the release of
untreated wastewater; collect the wastewater, and restore any possible environmental
impacts. Further, it demonstrates the City of Durham Department of Water Management's
(DWM) strong commitment to and investment in preventing and mitigating sanitary sewer
overflows (SSO). All conditions of the City's Collection System permit are met by the
Department, including system cleaning, site visits, inspections, and easement maintenance.
As such, we respectfully request that no civil penalties be assessed for the SSOs that occurred in
the City's wastewater collection system between May 1, 2024 and May 31, 2024.
Incident##202400846 — May 1, 2024 — 400 Muldee Street
On May 1, 2024 at 12:08 PM, an overflow occurred near 400 Muldee Street releasing an
estimated 860 gallons of wastewater into a tributary of Eilerbe Creek. Crews discovered that
vandalism was the primary cause of the spill as they found the manhole ajar with wood and
concrete debris clogging the infrastructure. Crews manually removed the debris and then used
a JetVac truck to successfully clear the line. After assessing the extent of the spill, crews

dammed the downstream creek with sandbags, set up a 4-inch pump to pump the untreated
wastewater back into the collection system, and flushed the area using a nearby hydrant
(dechlorinated water). This approach contained the sewer flow and minimized the
environmental impact on the surrounding land and downstream waters.
Crews replaced the standard manhole lid and casting with a bolt -down model in order to
prevent future tampering and vandalism. In addition, crews completed manhole inspections on
the nearby manholes to ensure no additional vandalism of the system had occurred and used a
JetVac truck to clean the three upstream and three downstream pipe reaches to ensure the
pipes were clear.
®® Gravity Main Cleaning Muldee SSO Area
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Legend
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- FY24
All Obff GmWy 1 W m
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Image 1. Spill locotion and identified gravity mains cleaned as part of remediation for incident#202400846
The City's Stormwater Services Division responded and conducted ammonia testing to
determine the spill's extent and advise the Department when the site returned to normal
conditions. Visual inspection of the affected area and downstream waters confirmed there
were no immediately visible adverse environmental impacts or hazards to persons or property,
including no fish kill or unnecessary vegetative damage.
The Department's cost to remediate this spill was $3,966.52.

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The incident leading to this spill is exceptional, unintentional, temporary, and caused by factors
beyond reasonable control. The staff immediately responded to the incident to mitigate the
impact of the spill and used every effort to ensure the infrastructure and environment was
restored. The Department replaced the standard infrastructure with bolted down manhole lids
to prevent further vandalism of the system at this location.
Incident #202401021— May 30, 2024 —1324 Maplewood Drive
On May 30, 2024 at 4:23 PM, an overflow was reported near 1324 Maplewood Drive releasing
an estimated 270 gallons of wastewater into a tributary of Ellerbe Creek. Crews discovered that
grease in the line was the primary cause of the blockage and used a JetVac truck to successfully
clear the line. After assessing the extent of the spill, crews dammed the downstream creek with
sandbags, set up a 6-inch pump to pump the untreated wastewater back into the collection
system, and flushed the area using a nearby hydrant (dechlorinated water). This approach
contained the sewer flow and minimized the environmental impact on the surrounding land
and downstream waters. Crews used a JetVac truck to clean the three upstream and three
downstream pipe reaches to ensure the pipes were clear.
In the follow up cleaning, crews found debris as well as grease in the manholes. Due to the
proximity of the spill to the City's Dearborn lift station, staff prioritized the cleaning of the
gravity main reaches Between the spill location and the lift station. No significant debris were
found during follow up with only moderate grease being identified in a few of the lines.
0� W
Gravity Main Cleaning Update - Dearborn P.S. Area
a ,
Legend Q�
Gravity Malm `
La CJ ..r 9 Q.1. /��\ YDearbornDweP.S.
FY2a1FY25
FY23 - FYta
A60&M Gra.tty Maim
CRY 07 d > `�
PiA eb
. 1 MMUH2Oa03 6 100 209 390 590 500 600 700 660 BOU 1,000
Feet
Image 4. Spill location and identified gravity mains cleaned as port of remediation for Incident#202401021

The City's Stormwater Services Division responded and conducted ammonia testing to
determine the spill's extent and advise the Department when the site returned to normal
conditions. Visual inspection of the affected area and downstream waters confirmed there
were no immediately visible adverse environmental impacts or hazards to persons or property,
including no fish !till or unnecessary vegetative damage.
The incident was reported to the Department's Industrial Waste staff so they could canvas the
neighborhood with information about the effects of non -woven and grease in the collection
system. Industrial Waste staff educate the community about the appropriate disposal options,
as well as providing interactive giveaways like grease trappers through the website. They
distributed 37 mailings regarding the appropriate disposal of nonwovens and grease to educate
the community.
The Department's cost to remediate this spill was $9,420.73.
The incident leading to this spill is exceptional, unintentional, temporary, and caused by factors
beyond reasonable control. The staff immediately responded to the incident to mitigate the
impact of the spill and used every effort to ensure the infrastructure and environment was
restored. The Department has made consistent efforts to prevent such an incident by regular
cleaning of the sewer system, a cyclical hot spot program, and constant engagement with the
community about proper waste removal. In addition, the Division coordinates with City paving
projects to perform pre -paving and post -paving inspections on manholes and gravity mains to
ensure that no debris enter the collection system.
Ongoing City -Wide Measures to Reduce the Occurrence of SSO Incidents
DWM has several programs in place to prevent and reduce the occurrence of 550 incidents.
DWM has implemented a Collection System Management, Operations & Maintenance (CMOM)
plan that expands and enhances its existing programs.
System Flushing and Inspection:
DWM routinely contracts cleaning, CCTV inspection, smoke testing, and manhole inspections of
portions of the sewer collection system. DWM completes the inspection of the collection
system systematically based on City defined geographical basins.
In FY23, DWM spent about $22 million on Sewer Rehabilitation projects as a part of its Capital
Improvements Programs. DWM ensures the requirements of the collection system permit are
met by deploying City crews to clean at least 10% of the collection system annually. DWM
measures the cleaning on a fiscal year basis starting July 1.

Reporting Period
Miles
Percent of System
FY24
134.97
11.72%
FY23
119.86
10.40%
FY22
116.16
10.14%
Table T. Unique mileage of gravity mains cleaned by DWM Staff for the three most recent fiscal years.
Sewer Rehabilitation Program:
DWM has an active Sewer Rehabilitation Program. The program includes flow monitoring (25
permanent monitors), CCTV inspection, manhole inspection, easement mowing, field
inspections and investigations, point repairs, line replacement, root and grease abatement and
cured -in -place manhole and line rehabilitation.
There are seven full-time equivalents (FTEs) employees dedicated to DWM's system
rehabilitation programs in the Utility Engineering Division of the Department. This workgroup
handles flow monitoring and system data management and contract preparation,
administration, and inspections.
There are 20 FTEs in the City's Collections Line Maintenance (CLM) workgroup in the Sewer
Maintenance Division of DWM. This group performs CCTV inspections, hydraulic cleaning
activities, manhole inspections, and manhole repairs. They respond to all reported concerns
including blockages and overflows. In addition, the CLM crews are supported by the Excavation
Services workgroup who perform identified point repairs, line replacements, and cured -in -place
lining.
The Lift Station Maintenance workgroup (LSM) focuses on oversight and maintenance of the 61
lift stations throughout the service area. This workgroup of 17 FTEs conducts required daily,
weekly, monthly, and annual inspections and associated preventive maintenance activities.
The 11 FTEs in the Outfall Maintenance (OFM) workgroup perform routine inspection and
mowing of easements and inspection of the designated high priority lines. In addition, they
facilitate the inspections and repair of the 136 air relief valves (ARVs) in the City's sewer
system.
Fats, Oils, and Grease Program (FOG):
The department's FOG education and outreach effort is conducted by three FTEs. (Staff are
shared between the Industrial Pretreatment, Septage and FOG Programs). In addition to
working with the Durham County Health Department, staff routinely inspect over 800 food
service establishments (FSEs) annually to ensure appropriate cleaning and maintenance of
grease interceptors. Staff participate in community events, such as Earth Day, Center Fest and
the Bimbe Festival, as well as neighborhood meetings. Department staff deliver residential Fat
Trappers to increase awareness of the proper disposal methods for waste. DWM staff also
conduct past-SSO follow-up education and enforcement as necessary. DWM invests over

$50,000 per year in advertising the proper disposal of FOG on television. Staff post to the City's
quarterly newsletter, the Durham Digest, along with multiple mentions in the City Manager's
Report known as City Connect, to reach a broad range of Durham residents.
Summary:
Based upon the documented information provided above regarding this incident, DWM
believes that this SSO was exceptional, unintentional, temporary, and caused by factors beyond
the City and Department's control. DWM actively manages, operates, and maintains its system
in such a manner as to meet or exceed all the requirements of the Collection System permit. As
detailed above, DWM systematically inspects, flushes, and rehabilitates its wastewater
collection system. The Department also actively works to regulate and educate the community
regarding what should and should not be discharged into the City's sewer collection system.
The department staff welcomes the opportunity to meet with you and your staff to review our
program and discuss constructive ways to improve what we are already doing in the City of
Durham. If you have any questions or need any additional information, please do not hesitate
to contact Kenny Willard, Collection System Maintenance Superintendent, at [phone] or
via email at [e-mail] or myself at [e-mail] .
Sincerely,
Donald F. Greeley
Director
Attachments
C: Kevin Fowler, DEQ— Water Quality Regional Operations Section, Raleigh Regional Office
Kenny Willard, Superintendent, Collection System Maintenance, Water Management
Scott Smart, Assistant Director, Water Management

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DocuSign Envelope ID: 10F42F48-42AF-42D4-9GD7-CA43A27D5747
P10Y COOPER
ELIZABETH S. MSER
RICHARD E. ROGERS, JR.
Donald F Greeley
City of Durham
101 City Hall Plz
Durham, NC 27701-3329
Environrucnt�i! Qatulity
June 07, 2024
SUBJECT: NOTICE OF VIOLATION
Tracking Number: NOV-2024-DV-0256
Sanitary Sewer Overflows - May 2024
Collection System Permit No. WQCS00005
Durham Collection System
Durham County
Dear Mr. Greeley:
RECEIVED
CXY Of Durham
�IUN 2 6 2024
Once of the Director
Dept. of Water Management
JUL 1 'i 2024
The self -reported Sanitary Sewer Overflow (SSO) 5-Day Report submitted by City of Durham indicates violations
of permit conditions stipulated in the subject permit and North Carolina G,S. 143-215.1. Violations include failing to
effectively manage, maintain, and operate the subject collection system so that there is no SSO to the land or
surface waters and making an outlet to waters of the State for purposes of G.S. 143-215.1(a)(1), for which a
permit is required.
Specific incident(s) cited in the subject report include the following:
Total Vol
Total Surface
Incident Start Duration Vol Water
Number Date (Mins) Location Cause (Gals) (Gals) DWR Action
202400846 5/1/2024 172 400 Muldee Street, Vandalism 860 860 Notice of Violation
Durham, NC, 27703
202401021 5/30/2024 27 1324 MAPLEWOOD Grease 270 270 Notice of Violation
DRIVE, DURHAM,
27704

DocuSign Envelope ID: 1OF42F48-42AF-42D4-36D7-GA43A27E]5747
Remedial actions, if not already implemented, should be taken to correct the above noncompliance. Please submit
a written response to this Notice of Violation. Your response is to be received by the regional office within 15
business days following receipt of this violation. Please include any additional documentation about this incident(s)
in the response. The submittal will be considered in determining whether the Division will assess a civil penalty for
the cited violations.
If you have any questions, please do not hesitate to contact Kevin Fowler with the Water Quality Section in the
Raleigh Regional Office at 919-791-4261 or via email at [e-mail].
Sincerely,
DocuS'sgned by:
Ualn c,SSa f . A aiuxd
BZ916�6RB32144F
Vanessa Manuel, Assistant Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
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DONALD F GREELEY
CITY OF DURHAM
191 CITY HALL PLAZA
DLIRAHM, NC Z7701

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State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Collection System Sanitary Sewer Overflow Reporting Form
nivlston of Water Resources Form CS-SSO
17112110
This form shall be submitted to the appropriate DWQ Regional Office within five business days of the first knowledge of the
sanitary sewer overflow (SSO).
Permit Number. WQCS00005
(WQCS# if active, otherwise use WQCSD#)
Facility: Durham Collection System Incident #: 202400846
Owner: City of Durham
City: Durham County: Durham Region: Raleigh
Source of SSO (check applicable): 0 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): 400 Muldee Street, Durham, NC, 27703
Manhole #: 16535
Latitude (Decimal Degrees): Longitude (Decimal Degrees):
Incident Started Dt: 05/0112024 Time: 12:08 pm Incident End Dt: 05/01/2024 Time: 03:00 pm
(mm-dd-yyyy) (hh:mm AM/PM) (mm-dd-yyyy) (hh:mm AMIPM)
Estimated Volume of the SSO: 860
gallons Estimated Duration (Round to nearest hour): 2:52 hours
Describe how the volume was determined: 172 Minutes X 5GPM
Weather conditions during the SSO event: Dry
Did SSO reach surface waters? 2 Yes ❑ No ❑ Unknown Volume reaching surface waters (gals): 860
Surface water name: Ellerbe Creek
Did the SSO result in a fish kill? ❑ Yes ❑ No Q Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
q Vandalism
24 hour verbal notification (name of person contacted }: Chris Chreighton
❑ DWR Q Emergency Mgmt Date (mm-dd-yyy): 05/01/2024 Time (hh:mm AMIPM): 04:10:00 em
If an SSO is ongoing, please notify the appropriate Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 or more of untreated wastewater to surface waters
shall issue a press release within 24-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a public notice shall be published within 10 days and proof of publication shall be provided to the Division within 30
days. Refer to the reference statute for further detail.
The Director, Division of Water Resources, may take enforcement action for SSOs that are required to be reported to
Division unless it is demonstrated that:
1) the discharge was cause by sever natural conditions and there were no feasible alternative 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 I I must be completed to provide a justification claim for either of the above situations. This information will be the basis
WHETHER OR NOT PART III IS COMPLETED A SIGNATURE IS REQUIRED AT THE END OF THIS FORM
CS-SSO Form Page: 1

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
Vandalism
Provide police report number:
NA
Was the site secured?
,WYes [71No ]NA [7NE
If Yes, how?
Will create a work order to get manhole sealed down and bolted to avoid any more issues in the area,
Have there been previous problems with vandalism at the SSO location? [7] Yes W No [, NA ❑ NE
If Yes, explain:
NA
What security measures have been put in place to prevent similar occurrences in the 7 Yes ❑ No ❑ NA ❑ NE
future?
Comments:
We will Proceed to get crews to have lid bolted down at manhole 16535 after follow up is complete, We will also monitor
this area to prevent future issues.
System Visitation
ORC ❑ Yes
Backup ,�7J Yes
Name:
Larry Edward Hughes
Cert#
1005483
Date visited:
05/01 /2024
Time visited:
2:30pm
CS-SSO Form Page: 2

How was the SSO remediated (i.e. Stopped and cleaned up)?
After crew arrived onsite they tried to stop overflow with mini flusher but were unsuccessful. They used 'et/vac combo to
flush line with vacuum tube in manhole. After knocking the pressure of the flow down they were able to see the sticks an(
concrete blocking the invert headed downstream. They removed the debris that had been tossed in the manhole
remediating all issues. Crews cleaned up around manhole removing all sail that was touched by wastewater and uttin
back seed and straw in the area. We set up a pump downstream with sandbags blocking the flow. We used the pump to
remove all untreated wastewater from Ellerbe Creek and pump it back into manhole 21666 where we tested for zero
ammonia levels. Crew will continue to monitor area until bolt down manhole is complete. Local storm water quality was
called to inform them as well of the overflow to test creek levels for pump removal.
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:
Edward Hughes
Telephone Number: "'1-4' '-o9 L-
Date: 05106/24 01:35 pm
Title: &J� 1� YL,
Any addition information desired to be submitted should be sent to the appropriate Division Regional Office within five days of f
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of th
form is completed, if used).
CS-SSO Form Page: 3

Mate of North Carolina
DWR
Department of Environment and Natural Resources
Division of Water Resources
Collection System Sanitary Sewer Overflow Reporting Form
Division of Water Resources Form CS-SSO
PART I;
This form shall be submitted to the appropriate DWQ Regional Office within five business days of the first knowledge of the
sanitary sewer overflow (SSO).
Permit Number: WQCS00005 (WQCS# if active, otherwise use WQCSD#)
Facility: Durham Collection System Incident #: 202401021
Owner: City of Durham
City: Durham
Source of SSO (check applicable):
County: Durham Region: Raleigh
[Z Sanitary Sewer ❑ Pump Station 1 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): 1324 MAPLEWOOD DRIVE, DURHAM, , 27704
Manhole #: 20803
Latitude (Decimal Degrees):
Longitude (Decimal Degrees):
Incident Started Dt: 0513012024 Time: 4:23 prn Incident End Dt: 05/30/2024 Time: 04:50 pm
(mm-dd-yyyy) (hh:mm AM1PM) (mm-dd-yyyy) (hh:mm AM/PM)
Estimated Volume of the SSO: 270 gallons Estimated Duration (Round to nearest hour): 0:27 hours
Describe how the volume was determined: EST 10gpmX27min
Weather conditions during the SSO event:
seasonal
Did SSO reach surface waters? Z Yes ❑ No ❑ Unknown Volume reaching surface waters (gals): 270
Surface water name: Ellerbe Creek
Did the SSO result in a fish kill? ❑ Yes Q No ❑ Unknown If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
[A Grease
24 hour verbal notification (name of person contacted ): Jerry Belcher
❑ DWR [ Emergency Mgmt Date (mm-dd-yyy): 05130/2024 Time (hh:mm AM/PM): 09:30:00 pm
If an SSO is ongoing, please notify the appropriate Regional Office on a daily basis until SSO can be stopped.
Per G.S. 143-215.1 C(b), the responsible party of a discharge of 1,000 or more of untreated wastewater to surface waters
shall issue a press release within 24-hours of first knowledge to all print and electronic news media providing general
coverage in the county where the discharge occurred. When 15,000 gallons or more of untreated wastewater enters surface
waters, a Qublic notice shall be published within 10 days and proof of publication shall be provided to the Division within 30
days. Refer to the reference statute for further detail.
The Director Division of Water Resources may take enforcement action for SSOs that are re uired to be reported to
Division unless it is demonstrated that:
1) the discharge was cause by sever natural conditions and there were no feasible alternative 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
WHETHER OR NOT PART III IS COMPL.ETED`A SIGNATURE IS REQUIRED AT THE END OF THIS FORM
CS-SSO Form Page: 1

PART H:
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
Grease
When was the last time this specific line (or wet well) was cleaned?
11 /04/ 16
Do you have an enforceable grease ordinance that requires new or retrofit of grease 0 Yes E No ❑ NA ❑ NE
traps/interceptors?
Have there been recent inspections andlor enforcement actions taken on nearby
restaurants or other nonresidential grease contributors?
Explain.
Residential Area
Have there been other SSOs or blockages in this area that were also caused by
grease?
When?
If yes, describe them,
Have cleaning and inspections ever been increased at this location?
Explain.
Have educational materials about grease been distributed in the past?
When?
and to whom?
F Yes F-, No W NA n NE
Yes F, No n NA M NE
Yes F No 0 NA ❑ NE
❑ Yes E No Wl NA ❑ NE
Explain?
Information about the SSO will be sent to our F.O.G program. Distribution of educational material will be coordinated
through the F.O.G program.
If the SSO occurred at a pump station, when was the wet well and pumps last
checked for grease accumulation?
Were the floats clean?
CS-SSO Form
Yes F]No ONA []NE
Page: 2

Comments:
System Visitation
ORC Yes
Backup 0 Yes
Name:
Warren Goodwin
Cert#
1007495
Date visited:
05/30/24
Time visited:
8:3flgm
How was the SSO remediated (i.e. Stopped and cleaned up)?
Crew cleared blockage with fetter. Dammed the creek downstream and pumped untreated waste water back into the
system. Solids removed via mechanical methods and hauled to treatment plant d[ying beds. Area seeded and strawed.
Crews have cleaned additional upstream and downstream mains and will followup with CCTV.
As a representative for the responsible party, 1 certify that the information contained in this report is true and accurate to the
best of my knowledge.
Person submitting claim: Goc' ,N _ Date:
Signature: W . .�.��L., �r� Title:
Telephone Number:g,g - sco �A'3w'1
ct "_t - 2K
Any addition information desired to be submitted should be sent to the appropriate Division Regional Office within five days of I
knowledge of the SSO with reference to the incident number (the incident number is only generated when electronic entry of th
form is completed, if used).
CS-SSO Form Page: 3