WQCS00173_Tropical Storm Overflow 5-Day Reports_20240814

NICDept pf.: "'!?y1,L;; 7-Al 0-11 Aliy
State of North Carolina
Department of Environment and Natural Resources
DWR
Division of Water Resources
AUG 14 204
Collection System Sanitary Sewer Overflow Reporting Form
L f-) Form CS-SSO
PART l:
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#) () 6 ( 7 3
Facility: S:tSAqe.• Incident *2P2401s(-7 Owner:'rp ivj Seov S — cp_,w
Region: Er
City: Tksv�. � �t- County:
Source of SSO (check applicable): Lr 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 m 3- (
Latitude (degrees/minutelsecond): Longitude (degrees/minute/second):
Incident Started Dt: Time: gpov Incident End Dt: Time: q. e'
(mrn-dd-yyyy) k1d't1u24 (hh:mm)AM/S (mm-dd-yyyy) 606420xV (hh:mm)AMIQ
Estimated volume of the SSO: 5Z�& gallons Estimated Duration (round to nearest hour): hour(s)
Describe how the volume was determined: :r ebA'' TJWMS V-6L%Iiy
Weather conditions during the SSO event: T6p &l
Did the SSO reach surface waters? [Ro"Yes ❑ No ❑ Unknown
Volume reaching surface waters: 5-ft gallons Surface water name: tf't 1 C.rrx k
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 091nflow & Infiltration
(--]Pump Station Equipment Failure ❑ Power Outage ❑Vandalism ❑ Debris in line ❑Pipe Failure (Break)
❑Other (Please explain in Part 11)
24-hour verbal notification (name of person contacted):
VWR ❑Emergency Management Date(mm-dd-yyy): y/2/L� Time:(hh:mmAM/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 1S REQUIRED SEE PAGE 13
Form CS-SSO PW I

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

LJVdvwri Ynr w�wv •wiu� wtiwn• w• wr�w.
How much advom MfBRmg cid you have and what actions vms taken In preparabon for Ow event?
r
C xnnr :
�ti,'cq ( ,OwO' Oti&Z dmIAOL4 CO, f n rh*s of
" "4-,r 0 zc( A,,avr rAt.� +hvo - Gjp—
Q 4w Jays acictv^u- w&nv,,!S *..J 4c4 A l*�
m aQ% J 44, J Cur w.r r
4At.rf- &.�LJOK3 � wE.•�lt .s � �c `�- bcc �- �+ ewe ��'fi t�er�
'^5 1 aftj Au .some U.; kore Pte Jr � 41,
Foam Cs-M Paw 3
5

�,
..
�. r
•
.�
_ ,
�.I
[ Jf.K'
..
I I 1
-��.I
Lp �
���
I li.
I �

Grease (Documentation such as cleaning ins 'on, 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 retroM 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
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 Page 4

Roots
Do you have an active root control program on the line / area in question? ❑ Yes ❑ No
Describe:
Have cleaning and inspections ever been increased at this location because
Of roots? ❑ Yes ❑ No
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?
Has the line been smoke tested or videoed within the past year?
If Yes, when?
Comments:
❑NA ❑ NE
❑NA ❑ NE
❑ Yes ❑ No ❑NA ❑ NE
Form CS-SSO Page 5

I IJ.. %e�. _:u •_•. �— .. .. _.WWII Iun�.
�I
n III

Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule ❑ Yes 9?eNo ❑NA ❑ NE
in any permit that addresses III?
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 Ill 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? L)C' h VVS ° "
Has the line been smoke tested or videoed within the past year? E Yes ❑ No ❑NA ❑ NE
If Yes, when and what actions are necessary and the status of such actions:
esn ar.g Luce,+- .
Are thed III related projects in your Capital Improvement Plan?
[�es
❑ No
[-_]NA ❑ NE
If Yes, explain: We- � �r.k* r+nor-W a •,.% a,. er .ee^ �
p
i,+Y,... 8 0►� a a�
Gt vu �y jjZ
Have there been any grant or loan applications for III reduction projects?
03 Yes
❑ No
❑NA ❑ NE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections
❑ Yes
[4Io
❑NA ❑ NE
with storm sewers?
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream LYes ❑ No ❑NA ❑ NE
been inspected recent
41( (i' s 0CW ,rde1W.1 rk Ally .Thu.
If Yes, explain:
What other corrective actions are planned to prevent future Ill related SSOs at this location?
Comments:
Form CS-SSO Page 6

6, U

Pump Station Equipment Failure (Documentation of testing records, etc should be provided upon request)
What kind of notification/alarm systems are present?
Auto-dialerAelemetry (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 altemate?
❑ 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
Was a spare or portable pump immediately available?
If a float problem, when were the floats last tested? Flow?
If an auto -dialer or SCADA, when was the system last tested? Hove?
Comments:
❑ Yes ❑ No ❑NA ❑ NE
❑ Yes ❑ No ❑NA ❑ NE
Form CS-SSO Pagc 7

Power outage (Documentation of testing, records, tee., should be provided of altemative 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?
1f 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 8

11 F'I-

Vandalism
Provide police report number:
Was the site secured? ❑ Yes ❑ No
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
occurrences in the future?
Comments:
❑NA
❑NA
❑ NE
❑ NE
Form CS-SSO Page 9

Debris in line (Rocks, sticks, races 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?
When was the area last checkedldeaned?
Have cleaning and inspections ever been increased at this location
due to previous problems with debris?
Explain:
Are appropriate educational materials being developed and distributed
to prevent future similar occurrences?
Comments:
❑ Yes ❑ No ❑NA
❑ Yes ❑ No [-]NA
❑ Yes ❑ No ❑NA
❑ NE
❑ NE
❑ NE
Form CS-SSO Page 10

Other (pictures and police report, as applicable, must be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem?
If Yes, explain:
If the problem could not be immediately repaired, what actions
were taken to lessen the impact of the SSO?
Comments:
❑ Yes ❑ No ❑NA
❑ Yes ❑ No ❑ NA
❑ NE
❑ NE
Form CS-SSO Page l I

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 line up and down stream 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 12

System Visitation
ORC '3-o,5h ; `� �c v �,S a v. Q'Yes
Backup-Tahf,r %,A" 'Yes
Name: �aS�n U� ; ��-\ ay..ga ,
Certification Number.Datevisited: &- k 'L tf
Time visited: 6 goo am
How was the SSO remediated (ide. Stopped and cleaned up)?
P.�- [ucd. �.�ri C fal+►wJ �rJ. Lr�•e ��.-�.�.
As a representative for the responsible Darts. I oertifv that the information contained in this resort is true and accurate to the
best of my knowledge.
Person submitting claim: AJ lip 4�w, 4,ti Date: b _� L - z Y
Signature: Title: LAS aeV_IItr
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

P1,;r
State of North Carolina
Department of Environment and Natural Resources
)w R AUG 14 2024 Division of Water Resources
Collection System Sanitary Sewer Overflow Reporting Form
�
ill(;,7 Yii T.�P T�i\rl y7j Form CS-SSO i I1r1•�P
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. (WOCS# if active, otherwise use WQCSD#)
Facility:Ka-%1y GAt4<61pA IncidentM2h'A4o142.y Owner.T w%( Scow Tokr-m mondj%--
Region: We--3k City.'rwrww b ^ County:
Source of SSO (check applicable): B"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 a jA f A 4 !X -pb,4 ak 3 r,).3
Manhole #: 3-3
Latitude (degrees/minute/second): Longitude (degrees/minute/second):
Incident Started Dt: Time: O V0 incident End Dt:0%•00-Uz4 Time: 9=�a
(mm-dd-yyyy) L $_ C S�- (hh:mm) AWM (mm-dd-yyyy) (hh:mm) AM/1119
Estimated volume of the SSO:r LGOgallons Estimated Duration (round to nearest hour): hours) / 3
Descobe how the volume determined:s QSh-4-c) .J.*- Jert c( lr. . s
Weather conditions dun'ng t e SSO even :"��; �� S
Did the SSO reach surface waters? WYes ❑ No ❑ Unknown
Volume reaching surface watemsi 10 gallons Surface water name: �M; jq
Did the SSO result in a fish kill? ❑ Yes N No ❑ Unknown
If Yes, what is the estimated number offish killed?
SPECIFIC cause(s) of the SSO:
&,evere Natural Conditions ❑ Grease
❑Pump Station Equipment Failure ❑ Power Outage
[-]Other (Please explain in Part 11)
[--]Roots [Inflow & Infiltration
[]Vandalism ❑ Debris in line []Pipe Failure (Break)
2tKur verbal notification (name of person contacted):
DWR []Emergency Management Date (mm-dd-yyy): Time: (hh:mm AM/119:
0V-44-zc..4 dyab
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 11 IS COMPLETED, A SIGNATURE IS REQUIRED SEE PAGE 13
Form CS-SSO Pagc I

Wd I
4 — I

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

��� II IL _ I 'i�

rvJNi w/V YrY w��.r�. •rWWW wrYwVr• Yr vrrw.
How mach advance wandng did you have and what arms were taken in prepandion for the event?
Commerft:
a Auj •µ,A A4,
Mack
r
Were- �r-�a.� � wt.•�lt c ci--c . — l [ t—vr
�
t jLhS t sores u.,w- !wJ P(.e", /r %fir
Form CS-m
e
5
3

Grease Documentation such as cleaning, ins Lion enforcement actions ast overflow reports— educational
material and distribution date, etc. should be available upon request)
When was the test 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 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 clean? ❑ Yes ❑ No DNA ❑ NE
Comments:
Fonn CS-SSO Page 4

Roots
Do you have an active root control program on the line / area in question? ❑ Yes ❑ No [-]NA
Describe:
Have cleaning and inspections ever been increased at this location because
of roots? ❑ Yes ❑ No ❑NA
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?
Has the line been smoke tested or videoed within the past year? ❑ Yes ❑ No ❑NA
If Yes, when?
Comments:
❑ NE
❑ NE
❑ NE
Form CS-SSO Page 5

Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule ❑ Yes Moo ❑NA ❑ NE
in any permit that addresses IA?
Explain N 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 IA problems in the
5? Yes
❑ No
❑NA
❑ NE
collection system at the SSO location?
If Yes, when was the study completed and what actions did it recommend?�j c,:.
¢ir�r�S
41vt�t�3•
Has the line been smoke tested or videoed within the past year?
Ves
O'No
❑NA
❑ NE
If Yes, when and what actions are necessary and the status of such actions:
9�x
eS
Itiat on en -ph -Mr
Are thererelated protects in your Capital Improvement Plan?
0 Yes
❑ No
❑NA
❑ NE
If Yes, explain: t" 6'-1- Vy" 3 qn "—en
4, W- &%.& a1-A7
Have there been any grant or loan applications for lA reduction projects?
('fifes
❑ No
❑NA
❑ NE
Ore ct ta. Cv&,b-h& ► Fs d0A9 .
If Yes, explain:
Do you suspect any major sources of inflow or cross connections
❑ Yes
V No
❑qA
❑ I E
with storm sewers?
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream
('Yes
❑ No
[DNA
❑ NE
been inspected recently? AIid��
v►' rk #1114c A
Jae .
If Yes, explain:
What other corrective actions are planned to prevent future IA related SSOs at this location?
Comments: C ct-e figs Sip V�-- t L J-e-d l act -Crbe, a tj's �C rn cr •�,�
gvcv SIG �L d ���/•
A Jell" W4. r)Zk-WJ- 4-10 avN) lqoa s"d )V, 4
ale a
Form CS-SSO Page 6

Pump Station Equipment Failure (Documentation of testing records, etc should beprovidedupon reouest)
What kind of notificadon/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
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 ❑ No ❑NA ❑ NE
❑ Yes ❑ No ❑NA ❑ NE
Form CS-SSO Page 7

Dower outage {E]ocumentatfon of testing, records, tec., should be provided of alternative power source upon
r uest
What is your alternate power or pumping source?
Did it function property? ❑ 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 8

- _i 1n =.r.. _i

Vandalism
Provide police report number:
Was the site secured? ❑ Yes ❑ No
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
occurrences in the future?
Comments:
❑NA
❑NA
❑ NE
❑ NE
Foam CS-SSO Page 9

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?
When was the area last checkedldeaned?
Have cleaning and inspections ever been increased at this location
due to previous problems with debris?
Explain:
Are appropriate educational materials being developed and distributed
to prevent future similar occurrences?
Comments:
❑ Yes ❑ No ❑NA
❑ Yes ❑ No ❑NA
❑ Yes ❑ No ❑NA
❑ NE
❑ NE
❑ NE
Form CS-SSO Page 10

Other (Pictures and police report as applicable, must be available upon request.)
Describe: -
Were adequate equipment and resources available to fix the problem?
If Yes, explain:
If the problem could not be immediately repaired, what actions
were taken to lessen the impact of the SSO?
Comments:
❑ Yes ❑ No ❑NA
❑ Yes ❑ No [-]NA
❑ NE
❑ NE
Form CS-SSO Page 11

NO 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?
Is this a force main line?
Is the line a "High Priority" tine?
Last inspection date and findings
If a force main then,
Was the break on the force main vertical?
Was the break on the force main horizontal?
Was the leak at the joint due to gasket failure ?
Was the leak at the joint due to split bell?
❑ Yes
❑ No
[:]NA
❑ NE
❑ Yes
❑ No
❑NA
❑ NE
❑ Yes
❑ No
❑NA
❑ NE
❑ Yes
❑ No
[-]NA
❑ NE
❑ Yes
❑ No
❑NA
❑ NE
❑ Yes
❑ No
❑NA
❑ NE
❑ 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 line up and down stream 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 12

System Visitation II
ORC TCISh WCI1itr-Sc- OkGs
Backup ����r Se-AA-e-- 191-19es
Name: -'SL,s � "0 W.
Certification Number. 1 o r 2 Z '7 4�-
Date visited: O k - Z `{
Time visited: 6 g-Gj ct,,n..
How was the SSO remediated (i.le. 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:
Signature:
Telephone Number: P (- )� _ 9 f f 2 `( 13
Date: 0 1 L` Z Y
Title: L/4-S U-C
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

State of North Carolina
Department of Environment and Natural Resources
DWR I AUG 14 2024 Division of Water Resources
Collection System Sanitary Sewer Overflow Reporting Form
Rar-'tu;t Retr:n 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: (WQCS# if active, otherwise use WQCSD#) 0 a 17 3
Facility: k'my CoWee- -0- -CyAY- Incident#: A*41°i5541 Owner:'tb%%\
Region: ,+tC�1� City:Tv6-*h 6� �4'"� 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.): 3 - 2 Xuo i2k%cL P44- -
Manhole M 3- 2-
Latitude (degrees/minute/second): Longitude (degrees/minute/second):
Incident Started Dt: Time: 610-0 Incident End Dt: dQ-48 zwL`f Time: OV41-0
(mm-dd-yyyy) O 1?-0 S- ZA Zvi (hh:mm) AM/I& (mm-dd-yyyy) (hh:mm) AM/00
Estimated volume of the SSO:5'0't> gallons Estimated Duration (round to nearest hour): S hour(s)
Describe how the volume was determined: t/i S � • (�' y
Weather conditions during the SSO event: ' "e" ( C To r an
Did the SSO reach surface waters? ER Yes ❑ No ❑ Unknown
Volume reaching surface waters: Vv gallons Surface water name: 1'ffii 1 sae. It
Did the SSO result in a fish kill? ❑ Yes J?rNo ❑ Unknown
If Yes, what is the estimated number of fish killed?
78e
IFIC causes) of the SSO:
vere Natural Conditions ❑ Grease
❑Pump Station Equipment Failure ❑ Power Outage
❑Other (Please explain in Part 11)
❑Roots Kiflow & Infiltration
❑Vandalism ❑ Debris in line ❑Pipe Failure (Break)
2ur verbal notification (name of person contacted):
DWR El Emergency Management Date (mm-dd-yyy): $/9/ 2r,i Time: (hh:mm AM/PM): ����� Zo2 t) l Z;1s
l0;1) A -
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 11 IS COMPLETED, A SIGNATURE IS REQUIRED SEE PAGE 13
Form CS-SSO Pagc I

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 It:
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)
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

Dbscribe ttre "severe natural cw4dorr in debB:
Haw -wd advance awnpg did you have and what actions were fatten in pmepwatkm for the event?
C.omrnents:
" sY-e-r 6 2c( kov,r "af +M'a. (J-4-
0- 4u-, 449 acfusj&cr-- wS a -.J ra. +L<4 A11nr.r4 C,v-L
Mack ScJ-,t & (( of 44-c pup, % 0- our- P" t s "tFv,--s
Wt rt- I h1.•�t � � �c `�- dace � `� e.:n.�r-�`�' 4.►er`Q
Gar-ker`.5 t San&kce f FaT-r� r 41,
Form CS-M ' Paac 3

Grease Documentation such as cleanina. i specUon, enforcement actions st overflow repgrts. educational
material and distribution date, etc. should be available upon rectums
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 4

I

Roots
Do you have an active root control program on the line 1 area in question? ❑ Yes ❑ No
Describe:
Have cleaning and inspections ever been increased at this location because
of roots? ❑ Yes ❑ No
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?
Has the line been smoke tested or videoed within the past year? ❑ Yes ❑ No
If Yes, when?
Comments:
❑NA ❑ NE
❑NA ❑ NE
❑NA ❑ NE
Form CS-SSO Page 5

Inflow and Infiltration �(
Are you under an SOC (Special Order by Consent) or do you have a schedule ❑ Yes Q No ❑NA ❑ NE
in any permit that addresses IA?
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 III problems in the Rf Yes ❑ No ❑NA ❑ NE
collection system at the SSO location?
If Yes, when was the study completed and what actions did it recommend? (A�� °" eKe'►eerm�
Has the line been smoke tested or videoed within the past year? DYes ❑ No ❑NA ❑ NE
If Yes, when and what actions are necessary and the status of such actions:
or, 6nyiKa-
Are there Ill related projects in your Capital Improvement Plan? ��"I 9Yes [I No ❑NA ❑ NE
If Yes, explain: wa {"t 3f►.a" rn�ne,� 4 ry f►�i sK G)Le+'p's 7' 00%, ifohS 4 N lt-44 1-
Have there been any grant or loan applications for UI reduction projects? R(Yes ❑ No ❑NA ❑ NE
If Yes, explain:
Do you suspect any major sources of inflow or cross connections ❑ Yes dNo [-]NA ❑ NE
with storm sewers?
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream Jj Yes ❑ No [_-]NA ❑ NE
been inspected recently? A,( Gas jy.„: I'm a 0(me"W rti. Mw 6 J „M -
If Yes, explain:
What other corrective actions are planned to prevent future IA related SSOs at this location?
Comments:
Form CS-SSO Page 6

Pump Station Equipment Failure (Documentation of testing records. etc should be provided upon request)
What kind of notification/alarm systems are present?
Auto-dialerAelemetry (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 a#temate?
❑ 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
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 ❑ No ❑NA ❑ NE
❑ Yes ❑ No ❑NA ❑ NE
Form CS-SSO Page 7

..a ii - I./. JI .N J.l I] it .AL ..IPa

Power outage (Documentation of testing. records, tec., should be grovided 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 &

Vandalism
Provide police report number:
Was the site secured? ❑ Yes ❑ No
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
occurrences in the future?
Comments:
❑ NA
❑NA
❑ NE
❑ NE
Form CS-SSO Page 9

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 tine?
Suspected cause or source of debris:
Are manholes in the area secure and intact?
When was the area last checked/cleaned?
Have cleaning and inspections ever been increased at this location
due to previous problems with debris?
Explain:
Are appropriate educational materials being developed and distributed
to prevent future similar occurrences?
Comments:
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑NA ❑ NE
❑NA ❑ NE
❑NA ❑ NE
Form CS-SSO Page 10

Other (Pictures and police reoork as applicable, must be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem?
If Yes, explain:
If the problem could not be immediately repaired, what actions
were taken to lessen the impact of the SSO?
Comments.
❑ Yes ❑ No ❑NA
❑ Yes ❑ No ❑NA
❑ NE
❑ NE
Form CS-SSO Page I I

Pine 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?
Is this a force main line?
Is the line a "High Priority' line?
Last inspection date and findings
If a force main then,
Was the break on the force main vertical?
Was the break on the force main horizontal?
Was the leak at the joint due to gasket failure ?
Was the leak at the joint due to split bell?
❑ Yes
❑ No
❑NA
❑ NE
❑ Yes
❑ No
❑NA
❑ NE
❑ Yes
❑ No
[:]NA
❑ NE
❑ Yes
❑ No
❑NA
❑ NE
❑ Yes
❑ No
[-]NA
❑ NE
❑ Yes
❑ No
[:]NA
❑ NE
❑ 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 line up and down stream 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 12

System Visitation
ORC %s� W • l"a�w�bar. Yes
Backup (�hh,�s �jw-��-ins. 4A Yes
Name: 'Ta S6- Li i i ( i Fw•j6 ,
Certification Number: f o j 227 ir
Date visited:
Time visited:
How was the SSO remediated (i.le. Stopped and cleaned up)?
Oeb�s p� , � - �
/ice spy
As a -representative for the responsible party. I certify that the information contained in this report is true and accurate to the
hest of my knowledge.
Person submitting claim: Date:
Signature: Title:
Telephone Number: A,1(2-3
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

State of North Carolina
;:... Department of Environment and Natural Resources
Division of Water Resources
DWR AUG 4MA
� Collection System Sanitary Sewer Overflow Reporting Form
Form CS-SSO
PART I:
This form shall be submitted to the appropriate DWR' Regionaf Offid6f !thin five business days of the first knowledge of the
sanitary sewer overflow (SSO).
Permit Number. (WQCS# if active, otherwise use WQCSD#)
Facility: ken "f &Vec-60A J�4t-, Incident *Paola'S�Z Owner:
Region: 19,13ecJ City:l?w% s( 4K. 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 B, Manhole at Westall & Bragg Street, etc.): WZ (j(oC o�. A& Ave,
Manhole #: 3~ -q
Latitude (degrees/minute/second): Longitude (degrees/minutelsecond):
Incident Started Dt: Time; O ft00 Incident End Dt: Time:
(mm-dd-yyyy) o If- G 9 (hh:mm) AM/ID (mm-dd-yyyy);5 ' �T 74 (hh:mm) AM/0 41'aw
Estimated volume of the SSO:SLD gallons Estimated Duration (round to nearest hour): �— hour(s)
Describe how the volume was determined: V >iv hflc(
Weather conditions during the SSO event: T;-*P «r S4rrr. oahtY
Did the SSO reach surface waters? Rf Yes ❑ No ❑ Unknown
Volume reaching surface waters:SW gallons Surface water name: P4,11 r��C �
Did the SSO result in a fish kill? El Yes [I o ❑ Unknown
If Yes, what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO:
ES evere Natural Conditions ❑ Grease [-]Roots M(nnflaw & Infiltration
[--]Pump Station Equipment Failure ❑ Power Outage ❑Vandalism ❑ Debris in line ❑Pipe Failure (Break)
❑Other (Please explain in Part II)
24ttpur verbal notification (name of person contacted):
[�WR ❑Emergency Management Date (mm-dd-yyy): Zy Time: (hh:mm AM/PM): Ja'? A/r'1
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
Form CS-SSO Page

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

Descrihe the "severe natruat axx&imf in detail:
Haw much advance wamuV dd you tww and what ac bxw were taken in preparation for the event?
Comments:
a 4-1 4 c4 A1*r
t t &"Dr M.�t JUG C Fr f�
hS ,ram stjr"e Ule- kKej Pl.e'O.. /r t,.( 41,
Form CSSSO Page 3

Grease.(Documentabon such as cleaning, inspection. enforcement actions, past overflow reports, educational
material and distribubon 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 trapsfinterceptors? ❑ 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?
Explain.
Have educational material about grease been distributed in the past?
When:
and to whom:
❑ Yes ❑ No ❑NA ❑ NE
❑ Yes ❑ No [—]NA ❑ NE
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 4

Roots
Do you have an active root control program on the line 1 area in question? ❑ Yes ❑ No ❑NA
Describe:
Have cleaning and inspections ever been increased at this location because
of roots? ❑ Yes ❑ No ❑NA
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?
Has the line been smoke tested or videoed within the past year? ❑ Yes ❑ No ❑NA
If Yes, when?
Comments:
❑ NE
❑ NE
❑ NE
Form CS-SSO Page 5

Inflow and Infiltration
Are you under an SOC (Special Order by Consent) or do you have a schedule ❑ Yes Vo ❑NA ❑ NE
in any permit that addresses IV
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 In problems in the Fi Yes ❑ No ❑NA ❑ NE
collection system at the SSO location?
If Yes, when was the study completed and what actions did it recommend? �+yS or+ e n3�7�ct.r•'� awa ��,fi S
Has the line been smoke tested or videoed within the past year? C9 Yes ❑ No ❑NA ❑ NE
If Yes, wthen and what actions are necessary and the status of such actions:
L/". on O'NNY m-1- �
Are there I related projects in your Capital Improvement Plan? & Yes ❑ No ❑NA ❑ NE
If Yes, explain: WC Aloe- YV-4. � rrwrwtt a,V/ as ��1 INce• .
604V,S ¢w 4w4IYSf
Have there been any grant or ban applications for Ill reduction projects? 9jrYes. ❑ No ❑NA ❑ NE
Q*%c.c- e&v»A,�4-
If Yes, explain:
Do you suspect any major sources of inflow or cross connections ❑ Yes MINo [-]NA ❑ NE
with storm sewers?
If Yes, explain:
Have all lines contacting surface waters in the SSO location and upstream E(Yes ❑ No ❑NA ❑ NE
been inspected recently?g(t
If Yes, explain:
What other corrective actions are planned to prevent future Ill related SSOs at this location?
Comments:
Form CS-SSO Page 6

Pump Station E ui ment Failure Documentation of testing records etc should be iprovided upon r uest
What kind of notification/alarm systems are present?
Auto-diafer/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 (Le. pump failure, power failure, high water, etc.)?
Were notifscation/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 attemate?
❑ 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
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 ❑ No ❑NA ❑ NE
❑ Yes ❑ No ❑NA ❑ NE
Form CS-SSO f',-W.c 7

Power outage (Documentation of testing, records, tec.. should be provided of alternative power source upon
rem
est
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 -SSA Page 8

Vandalism
Provide police report number:
Was the site secured? ❑ Yes ❑ No
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
occurrences in the future?
Comments:
❑NA
❑NA
❑ NE
❑ NE
Form CS-SSO Page 9

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?
Have cleaning and inspections ever been increased at this location
due to previous problems with debris?
Explain:
Are appropriate educational materials being developed and distributed
to prevent future similar occurrences?
Comments:
❑ Yes ❑ No ❑NA
❑ Yes ❑ No [:]NA
❑ Yes ❑ No ❑NA
❑ NE
❑ NE
❑ NE
Form CS-SSO Page 10

Other (Pictures and police report, as applicable, must be available upon request.)
Describe:
Were adequate equipment and resources available to fix the problem?
If Yes, explain:
If the problem could not be immediately repaired, what actions
were taken to lessen the impact of the SSO?
Comments:
❑ Yes ❑ No ❑NA
❑ Yes ❑ No ❑NA
❑ NE
❑ NE
Form CS-SSO Page I I

Pipe Failure (Break)
Pipe size (inches)
What is the pipe material
What is the appropmate 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 Prionty" 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 perfom*d?
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 line up and down stream 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
Forth CS-SSO Page 12

System Visitation
ORC �0 Sin W » t a+M Su r j "Yes
Backup "darn n� ^ ayes
Name: �b5� W r iki 4019ts+n
Certification Number: (e\ 2. 2 `7 S
Date visited: ¢• 8- Z o z 4
Time visited: V,Ot> PFP%
Mow was the SSO remediated (i.le. 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:
Signature:
Telephone Number:
Date: t, 12 ` Z Y
Title:
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

h d I
wl �