WQCS00146_SSO 5-day Report_Incident#202401555_20240809

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State of North Carolina
Department of Environment and Natural Resources
D .
Division of Water Resources
�* Collection System Sanitary Sewer Overflow Reporting Form
Division of Winer 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).
Permit Number: 41 (WQCS#if active,otherwise use WQCSD#)
Facility: TA"VL 6ef;14A6rd _ Incident#. 2 O 2 4 O 1. Owner: Ci43 g so-'XIJ
Region: 9'2 L j h City: P'++&60 rD County: L in&.4�a rn
Source of SSO(check applicable): K 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.): M,..1-I m 3 L 1 -4 4 4 9 5. 5 r,a
Manhole#: 3 (P'
Latitude(degrees/minlItRlsecond): Longitude(degrees/minute/second):
Incident Stacked Dt: "-,:& a Time: O 1 = 0 D Incident End Dt: 01-6 4DZ4 Time: 11 : DQ _
(mm-dd-yyyy) (hh:mm)AM0 (mm-dd-yyyy) (hh:mm)Al&
Estimated volume of the SSO: (0 0o p gallons Estimated Duration(round to nearest hour): jo hour(s)
Describe how the volume was determined: VI Sra&I
Weather conditions during the SSO event: - a t - h a my N ru-,% j f rAr a
Did the SSO reach surface waters? K Yes ❑ No ❑ Unknown /�
Volume reaching surface waters: (a D p 0 ,gallons Surface water name: 906c5an C r` r'
Did the SSO result in a fish kill? El 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 ll)
24-hour verbal notification(name of person contacted): CjNCt,S Mi 4AI
'KDWR ❑Emergency Management Date(mm-dd-yyy): Q Time:(hh:mm AM/PM): 10 AM
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 OF NOT PART II IS COMELETED.A SIGNATURE IS REQUIRED SEE PAGE 13A SIGNATURE IS REQUIRED SEE PAGE 13
Form CS-SSO f'agc ]

r
In order to submit a claim for justification of an SSO,you must use Part 11 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
QOMPLETE ONLY THOS-F—SECTONS PERRINING TO THE CAUSE OF THE SSO AS CHECKE12 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:
l +er M De 6bu - 14ea.vy ream Ll l r &r-f rf-f
r'nQ► ;el Ieka if yr C nc Ir m kdL--s
How much advance warning did you have and what actions were taken In preparation for the event? . d. .,
Comments: ,n r3 a !'� "%wa W;�n_
J
Form CS-SSO Pape 3

Grease Documentation such as cleaning, inspection,enforcement actionspast 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- DNA ❑ NE
Explain:
Have there been other SSOs or blockages in this areas that were also caused
by grease ❑ Yes ❑ No DNA ❑ NE
When?
If yes,describe them:
Have cleaning and inspections ever been done at this location? ❑ Yes ❑ No DNA ❑ NE
Explain.
Have educational material about grease been distributed in the past? ❑ Yes ❑ No DNA ❑ 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 dean? ❑ Yes ❑ No ❑NA ❑ NE
Comments:
Form CS-SSO pzi�e 4

System Visitation
ORC KYes ❑ No
Backup ❑ Yes ❑ No
Name: Alvan to my-
Certification Number. "1 9 7,z �o_ ....
Date visited: - A
Time visited: 1 Do PA1
How was the SSO remediated(ide.Stopped and cleaned up)?
wt. hJ , fin, waki Poe -+tie apee,V- 4p D c pon �o
ow nojra1 level. r tx _ __ ..ar•l l�`+N► .
As a representative for the ragponsible paft, I gArtifY that the informalloncontained this report is true and accurate to the
best of my knowledge.
Person submitting claim: 1'*lVOk Le x�ti bate: C OS
Signature: Title: �t br��+brti� E�¢ M14►•`S C'
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

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