WQCS00193_Compliance Evaluation Inspection_20180612

,
ROY COOPER
Goi-erno,-
._,. MICHAEL S.REGAN
Secretary
LINDA CULPEPPER
n F int Interim Director
June 12, 2018
Adam Mitchell, Town Manager
401 Old Honeycutt Road
Fuquay-Varina, NC 27526
Subject: Compliance Evaluation Inspection
Fuquay-Varina Collection System
WWCS Permit WQCS00193
Wake County
Dear Mr. Mitchell:
On May 31, 2018, Vanessa Manuel from the Raleigh Regional Office conducted an inspection of the town's
wastewater collection system to evaluate compliance with the operation and maintenance of the subject
wastewater collection system permit. The cooperation and assistance of James Jordan, Wastewater Collection
Supervisor and Operator in Responsible Charge (ORC), during the inspection were greatly appreciated.
Our records indicate the wastewater collection system consists of approximately 138 miles of gravity sewer,
approximately 20 miles of force main, 24 duplex pump stations, 1 triplex pump station, and 25 high priority
sewer lines.
The subject permit-is effective from November 1, 2016, until October 31, 2024, and is subject to specific
conditions and limitations. The items below show what conditions were noted during the inspection:
1. Reported Sanitary Sewer Overflows. During the period May 1, 2016, through April 30, 2018,there
were 12 reportable SSOs from the town's collection system with a combined estimated volume of
330,000 gallons, of which 325,600 gallons reached surface water. The SSOs occurring on September
16, 2016, February 13 and December 28, 2017, resulted in this office issuing the town Notices of
Violation. The SSO occurring on June 25, 2017, resulted in this office issuing the Town a penalty
assessment. No fish kills were reported because of the SSO events.
2. Fats, Oils and Grease Program. The Town of Fuquay-Varina, hereinafter referred to as the Town has
developed and implements an educational fats, oils and grease program that includes at least bi-annual
distribution of educational material targeted at both residential and non-residential users. The Town has
also developed and implements an enforceable FOG program for non-residential users.
3. Capital Improvement Plan. The Town has adopted and implements a Capital Improvement Plan to
designate funding for reinvestment into the wastewater collection system infrastructure. The CIP covers
the five-year period ending 2023, includes a goal statement, description of the project area, description
of the existing facilities, known deficiencies and forecasted future needs. The approximate capital
improvement budget for the collection system is $3,340,950, and the total annual revenue for
wastewater collection and treatment is $7,248,079.
State of North Carolina I Environmental Quality I Water Resources I Raleigh Regional Office
1628 Mail service Center I Raleigh,North Carolina 27699-1628
919 7914200
t } .fFw51i> d"4"-':" y r'.ETA A.s. ,'C'14"12114 t dl, tAiiiinfitee64

Town of Fuquay-Varina, WQCS00193
June 12, 2018
I
4. Contingency Plan for Pump Failure. The Town maintains a contingency plan for pump failure at each
lift station. The operator stated that\in the event of a pump failure at a lift station,the collection system
operators would immediately initiate the repair and/or replacement of the failed pump.
5. Pump Stations Inspected. The fol\\wing duplex pump stations were inspected: Station# 6,North/West
Regional Sewer Lift Station; Stationll# 13 —Middle Creek Sewer Lift Station; Station# 16—Eastern
Regional Sewer Lift Station(triplex pump station); Station# 19—Basal Creek Sewer Lift Station; and
Station#20—Herbert Akins Road Elementary School. The inspectors' observations noted in the next 5
items below refer to the five pump s-Ltions inspected. Overall, the pump stations were well maintained.
The wet wells were free of excessive\debris and grease, and the inspector did not observe any signs of
recent overflow. The on-site permanent generators were tested during the inspection, and no issues of
concern were noted. The fuel level for each generator was at or near full. The operators inspect each
pump station at least weekly and the permanent generators are tested biweekly.
6. Pump Station Signage. Each pump station has signage clearly and conspicuously posted that identifies
the pump station, provides an emergeicy 24-hour contact telephone number(s), and provides
instructions for notification if the visual'alarm illuminates and/or the audible alarm sounds, or if an
emergency is apparent. {
7. Pump Station �':estricted Access. Ti pump station sites, equipment and components were observed to
have restricted access.
8. Pump Stations Automatic Polling Feature. The pump stations are equipped with an automatic polling
feature that allow the collection system operators routine contact with the pump stations from a central
location to check the operational statu i of the pump stations.
9. Pump Station High Water Alarms. The pump stations are equipped with audible and visual high water
alarms. During the inspection,these all\ms functioned properly.
10. Pump Station Inspection Program. The Town has developed and implements a routine inspection of
each pump station that includes the following maintenance activities: cleaning and removing debris
from the pump station area and wet well; inspecting all valves; inspecting pumps and other mechanical
equipment; and verifying the proper operation of the alarms,telemetry system and auxiliary equipment.
The inspector reviewed the inspection lks of the pump stations visited and observed adequate entries of
the date and time of the operator's inspection, observations made, and any maintenance, repairs, or
corrective actions taken.
11. Designated Operators. The Town's w stewater collection system is classified as a CS-3 system, and
the designated certified Operator in Responsible Charge (ORC) and back-up ORCs on record are James
S. Jordan(ORC), Chris E. Grimes (BU), and Jonathan L. Joyner (BU). The certification type and status
for each operator is reflected as CS-4 an active, respectively, in the Division's data system. During the
inspection,the ORC stated that Charles leasant, CS-3, is also a back-up ORC for the system. Please
complete and submit to the Division the ttached Water Pollution Control System Operator
rlesignation Form to designate Mr. Plea ant as a back-up ORC.
12. Cleaning Sewer Lines. The Town has d veloped and implements a program for cleaning the sewer
lines. As required by Section II.8 of the ubject petiuit, at least 10% (or 72,864 feet) of the wastewater
collection system should be cleaned each year. Preventative cleaning is not required for sewer lines less
than five years old, unless an inspection r veals the need for cleaning. The ORC provided
documentation during the inspection showing 76,100 feet of sewer lines were cleaned during calendar
year 2017.
13. Spill l"esponse Action Plan. The Town as developed and maintains a Spill Response Action Plan that
• includes 24-hour contact numbers,respon e time, equipment list and spare parts inventory, access to

,
Town of Fuquay-Varina,WQCS00193
June 12, 2018
cleaning equipment, access to construction crews, sources of emergency funds, site sanitation and
cleanup materials, and post-SSO assessment.
14. SSO Records. The Town has maintained adequate records pertaining to SSOs and sewer complaints for
the three-year period ending April 2018. The last reportable SSO occurred on January 1, 2018.
15. Comprehensive Sewer Map. The Town maintains an up-to-date comprehensive map (electronic and
paper-based) of its sewer collection system. The map includes pipe size, pipe material,pipe location,
flow direction, approximate pipe age, number of active service taps, and each pump station
identification, location and capacity.
16. Inspection of High Priority Lines. As required by Section V.4 of the subject permit, an inspection of
all high priority sewer lines shall be performed at least once every six-months. The ORC stated the
operators inspect all high priority sewer lines at least 3 times per year. In addition,the ORC stated all
high priority lines are inspected after major storm events. During the inspection, the following high
priority lines were inspected: HP Line 1 —Angier Road (18-inch pipe); HP Line 1a—Angier Road (12-
inch pipe); HP Line 6—Pine Street (8-inch pipe); HP Line 9—Holland Road(8-inch pipe); HP Line 10
—Holland Road (8-inch pipe); and HP Line 11 —Holland Road (18-inch pipe). All observed high
priority sewer lines were free of visible damage, the rights-of-way were free of non-utility motorized
traffic and were well maintained and accessible. The observed aerial lines crossing creeks (HP Lines 1,
1 a and 6)had good support and were in good condition.
If you have questions or comments about this inspection or the requirements to take corrective action if
applicable, please contact Vanessa Manuel . 919-791-4255.
Sincerely,
S. Daniel Smith, Supervisor
Water Quality Regional Supervisor
Raleigh Regional Office
Attachment(s): Collection System Inspection Report
Water Pollution Control System Operator Designation Form
Cc: James Jordan, Fuquay-Varina Wastewater Collection Supervisor (same mailing address as town manager)
RRO/SWP Files
PERCS Unit
1i121i 1C'

r
Compliance Inspection Report
Permit: WQCS00193 Effective: 11/01/16 Expiration: 10/31/24 Owner: Town of Fuquay-Varna
SOC: Effective: Expiration: Facility: Fuquay-Vanna Collection System
County:Wake
Region: Raleigh
Contact Person: Chris E Grimes Title: Utility Operations Superintendent Phone: [phone]
Directions to Facility:
System Classifications: CS3,
Primary ORC: James Shelton Jordan Certification: 994460 Phone: [phone]
Secondary ORC(s):
On-Site Representative(s): i.�tN1t5
Related Permits:
NC0021636 Hamett County-North Hamett Regional WWTP
NC0066150 Town of Fuquay-Varina-Brighton Forest WWTP
NC0066516 Town of Fuquay-Varina-Terrible Creek WWTP
Inspection Date: 05/31/2018 Entry Time: 09 25AM Exit Time: 02 OOPM
Primary Inspector: Vanessa E Manuel f �i2Jyj� �J Phone: 9-1-8=89-7=6392 9r�/
Secondary Inspector(s):
Reason for Inspection: Routine Inspection Type: Collection System Inspect Non Sampling
Permit Inspection Type: Collection system management and operation
Facility Status: ® Compliant EI Not Compliant
Question Areas:
Miscellaneous Questions rt Performance Performance Standards E Operation&Maint Reqmts
19 Records ® Monitoring&Rpting Reqmts Inspections
Pump Station EN Lines
(See attachment summary)
Page. 1

Permit: WQCS00193 Owner-Facility:Town of Fuquay-Varina
Inspection Date: 05/31/2018 Inspection Type:Collection System Inspect Non Sampling Reason for Visit: Routine
Inspection Summary
See attached inspection report
Page 2

Permit: WQCS00193 Owner-Facility:Town ofFuquay-Varina
Inspection Date: 05/31/2018 Inspection Type:Collection System Inspect Non Sampling Reason for Visit: Routine
Performance Standards
Yes No NA NE
Is Public Education Program for grease established and documented'? ❑ 0 0
What educational tools are used'?
Flyers are sent to residential and business customers twice per year as an insert with the water/sewer bill.
Is Sewer Use Ordinance/Legal Authority available'? moi` 0 0 ❑
Does it appear that the Sewer Use Ordinance is enforced'? ❑ 0 ❑
Is Grease Trap Ordinance available'? ❑ Id 0 ❑
Is Septic Tank Ordinance available(as applicable,i.e.annexation) ❑ 0 „'3 0
List enforcement actions by permittee,if any,in the last 12 months
Has an acceptable Capital Improvement Plan(CIP)been implemented'? :w: ❑ ❑ ❑
Does CIP address short term needs and long term\"master plan\"concepts'? w;i ❑ 0 ❑
Does CIP cover three to five year period'? ❑ ❑ ❑
Does CIP include Goal Statement'? ® ❑ ❑ ❑
Does CIP include description of project area? tl ❑ 0 ❑
Does CIP include description of existing facilities? NI ❑ 0 ❑
Does CIP include known deficiencies'? ® ❑ ❑ ❑
Does CIP include forecasted future needs'? 1- ❑ 0 ❑
Is CIP designated only for wastewater collection and treatment'? ' ❑ ❑ ❑
Approximate capital improvement budget for collection system'? $3,340,950.00
Total annual revenue for wastewater collection and treatment'? $5,768,419 00
CIP Comments
Although the town does not have a grease trap ordinance,the town does implement and enforce grease trap
requirements.
Is system free of known points of bypass'? _ , ❑ ❑ ❑
If no,descnbe type of bypass and location
Is a 24-hour notification sign posted at ALL pump stations'? ® ❑ ❑ ❑
#Does the sign include
Instructions for notification'? •`1 ❑ ❑ ❑
Pump station identifier? i ❑ ❑ ❑
24-hour contact numbers g3 ❑ ❑ ❑
If no,list deficient pump stations
#Do ALL pump stations have an"auto polling”feature/SCADA? i.,%1 ❑ ❑ ❑
Number of pump stations 25
Number of pump stations that have SCADA 25
Number of pump stations that have simple telemetry 25
Number of pump stations that have only audible and visual alarms 0
Page: 3

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Permit WQCS00193 Owner-Facility:Town of Fuquay-Varina
Inspection Date: 05/31/2018 Inspection Type:Collection System Inspect Non Sampling Reason for Visit Routine
What areas are scheduled for cleaning in the next 12 months?
Is a Spill Response Action Plan available? ' 0 0 0
Does the plan include
24-hour contact numbers ! 0 0 0
Response time ^ ❑ 0 0
Equipment list and spare parts inventory 'Y 0 0 0
Access to cleaning equipment 0 0 0
Access to construction crews,contractors,and/or engineers ® 0 0 0
Source of emergency funds 41 0 0 0
Site sanitation and cleanup materials 0 0 0
Post-overflow/spill assessment ® ❑ ❑ ❑
Is a Spill Response Action Plan available for all personnel'? ;,4i 0 0 0
Is the spare parts inventory adequate? % 0 0 0
Comment. The town cleaned 76,100 feet of sewer line in 2017.
Records Yes No NA NE
Are adequate records of all SSOs,spills and complaints available'? 'h` 0 0 0
Are records of SSOs that are under the reportable threshold available'? r' 0 0 0
Do spill records indicate repeated overflows(2 or more in 12 months)at same location'? 0 k21 0 0
If yes,is there a corrective action plan'? 0 0 0
Is a map of the system available'? 0 0 0
Does the map include'
Pipe sizes 7 0 0 0
Pipe materials 0 0 0
Pipe location 0 0 0
Flow direction ® 0 0 0
Approximate pipe age �:, ❑ 0 0
Number of service taps E ❑ 0 0
Pump stations and capacity MI 0 0 0
If no,what percent is complete'?
List any modifications and extensions that need to be added to the map
#Does the permittee have a copy of their permit? ® 0 0 0
Comment: Since the last inspection,which was conducted May 26, 2016, the town has added flow direction
to its comprehensive map.
Monitoring and Reporting Requirements Yes No NA NE
Are copies of required press releases and distribution lists available'? 0 0 0
Are public notices and proof of publication available'? 0 0 ❑
Page. 5

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Permit: WQCS00193 Owner-Facility:Town of Fuquay-Varna
Inspection Date: 05/31/2018 Inspection Type:Collection System Inspect Non Sampling Reason for Visit: Routine
Instructions for notification? y, ❑ El El
Pump station identifier? •'i El 0 ❑
Emergency phone number ® ❑ El El
Is public access limited'? ® ❑ ❑ ❑
Is pump station free of overflow piping'? ® ❑ ❑ El
Is the pump station free of signs of overflow'? m ❑ 0 ❑
Are run times comparable for multiple pumps? Yes
Comment
EASTERN REGIONAL - 25
Pump Station
Yes No NA NE
Pump station type Triplex
Are pump station logs available? ❑ ❑ El
Is it accessible in all weather conditions? ^ El El 0
#Is general housekeeping acceptable? a ❑ ❑ ❑
Are all pumps present? ® ❑ 0 El
Are all pumps operable'? ❑ 0 El
Are wet wells free of excessive debris? :

Permit: WQCS00193 Owner-Facility:Town of Fuquay-Varina
Inspection Date• 05/31/2018 Inspection Type:Collection System Inspect Non Sampling Reason for Visit: Routine
Is a 24-hour notification sign posted? ❑ El ❑
Does it include'
Instructions for notification'? e ❑ ❑ ❑
Pump station identifier? ® ❑ ❑ ❑
Emergency phone number ❑ ❑ ❑
Is public access limited'? :"W' El ❑ ❑
Is pump station free of overflow piping? w DI ❑ ❑
a
Is the pump station free of signs of overflow? i;t ❑ ❑ El
Are run times comparable for multiple pumps? Yes
Comment: The wet well with 2 pumps was lined with inspector shield,which seals cracks in the concrete
wall. At this lift station,the operators have the ability to send wastewater flow to either Harnett
County or Terrible Creek WWTP.
BASAL CREEK SEWER - 6
Pump Station Yes No NA NE
Pump station type Duplex
Are pump station logs available? a.7 ❑ El ❑
Is it accessible in all weather conditions? -€ El El ❑
#Is general housekeeping acceptable? ❑ ❑ El
Are all pumps present? ® ❑ ❑ ❑
Are all pumps operable? • El El ❑
Are wet wells free of excessive debris'? ❑ ❑ ❑
Are upstream manholes free of excessive debris/signs of overflow? El El ❑
Are floats/controls for pumps/alarms operable? ❑ ❑ El
Is"auto polling"feature/SCADA present? ❑ ❑ El
Is"auto polling"feature/SCADA operational? ❑ ❑ ❑
Is simple telemetry present? _ ❑ ❑ ❑
Is simple telemetry operational? ❑ ❑ ❑
Are audio and visual alarms present? ❑ El ❑
Are audio and visual alarms operable? ® ❑ El ❑
Is the Pump station inspected as required'? 1r ❑ El El
Are backflow devices in place? ❑ ❑ ❑ kl
Are backflow devices operable'? El El ❑ i
Are air relief valves in place? ❑ ❑ ❑
Are air relief valves operable'? El ❑ ❑ ill
# Is an emergency generator available'? ❑ ❑ ❑
Can the emergency generator run the pumps'? A El ❑ ❑
Is the pump station equipped for quick hook-up? ❑ ❑ ❑
Page 9

Permit WQCS00193 Owner-Facility:Town of Fuquay-Varina
Inspection Date: 05/31/2018 Inspection Type:Collection System Inspect Non Sampling Reason for Visit: Routine
Is the generator operable? ® ❑ ❑ 0
#Is fuelin tank and sufficient? ❑ 0 0
Is the generator inspected according to their schedule? 0 0 0
Is a 24-hour notification sign posted? • 0 ❑ 0
Does it include
Instructions for notification? 0 ❑ El
Pump station identifier? s 0 ❑ 0
Emergency phone number A 0 0 El
Is public access limited? 4 0 0 0
Is pump station free of overflow piping'? 4r El 0 0
Is the pump station free of signs of overflow? " ❑ 0 0
Are run times comparable for multiple pumps? Yes
Comment:
HERBERT AKINS RD - 226
Pump Station
Yes No NA NE
Pump station type Duplex
Are pump station logs available? Ei El ❑ 0
Is it accessible in all weather conditions? E 0 0 0
#Is general housekeeping acceptable'? a ❑ El 0
Are all pumps present? l ❑ El El
Are all pumps operable? iA ❑ ❑ ❑
Are wet wells free of excessive debris'? ❑ 0 El
Are upstream manholes free of excessive debris/signs of overflow'? El 0 0
Are floats/controls for pumps/alarms operable'? ❑ ❑ 0
Is"auto polling"feature/SCADA present? 0 0 0
Is"auto polling"feature/SCADA operational? ® 0 El ❑
Is simple telemetry present? ❑ ❑ ❑
Is simple telemetry operational? ❑ ❑ 0
Are audio and visual alarms present? M ❑ ❑ ❑
Are audio and visual alarms operable? El ❑ 0 0
Is the Pump station inspected as required'? RI ❑ ❑ El
Are backflow devices in place'? El ❑ ❑
Are backflow devices operable'? ❑ El 0 El
Are air relief valves in place'? El El El
Are air relief valves operable'? ❑ ❑ El
# Is an emergency generator available'? E ❑ 0 El
Page. 10

Permit: WQCS00193 Owner-Facility:Town of Fuquay-Varina
Inspection Date: 05/31/2018 Inspection Type:Collection System Inspect Non Sampling Reason for Visit: Routine
Can the emergency generator run the pumps? wyj ❑ ❑ 0
Is the pump station equipped for quick hook-up? 0 0 0
Is the generator operable? 0 0 0
#Is fuel in tank and sufficient? 0 0 0 PE
Is the generator inspected according to their schedule? „rl 0 0 ❑
Is a 24-hour notification sign posted? ® 0 0 0
Does it include
Instructions for notification? ® 0 0 ❑
Pump station identifier? 0 0 0
Emergency phone number ❑ ❑ ❑
Is public access limited? ® 0 0 0
Is pump station free of overflow piping? M ❑ ❑ ❑
Is the pump station free of signs of overflow? ® 0 0 ❑
Are run times comparable for multiple pumps? Yes
Comment: This lift station does not have a permanent generator on site. The lift station serves the
elementary school only. The lift station will eventually go off line and the wastewater will be
gravity fed to the next lift station.
#1 ANGIER RD - Angier Rd
Lines/Right-of-ways/Aerie)Lines Yes No NA NE
Is right-of-way accessible for emergency? ® ❑ ❑ ❑
Is nght-of-way free of sinkholes-or-depressions? - ® 0 0 ❑
Is line/right-of-way free of evidence of leakage? 0 0 0
#Are there areas of exposed line? ® ❑ ❑ ❑
#Is any exposed line constructed of ductile iron or other approved material? a ❑ ❑ ❑
Are water crossing and supports in good condition? ® 0 0 0
#Is right-of-way free of non-utility motorized traffic? . ❑ El ❑
Is line free of visible damage? ❑ ❑ ❑
#Are there siphons in this system? ❑ ❑ ❑
If yes,are they maintained and documented?
Comment. This line is an aerial/creek crossing high priority line that is an 18-inch ductile iron pipe. This line
was originally concrete, but was completely replaced in 2016. Pipe joints are mechanical.
#1A ANGIER RD - Angier R
Lines/Right-of-ways/Aeriel Lines Yes No NA NE
Is right-of-way accessible for emergency? ® 0 0 0
Is right-of-way free of sinkholes or depressions? 1 El 0 El
Is line/nght-of-way free of evidence of leakage? 0 ❑ 0
#Are there areas of exposed line? E 0 ❑ ❑
Page 11

Permit: WQCS00193 Owner-Facility Town of Fuquay-Varina
Inspection Date• 05/31/2018 Inspection Type•Collection System Inspect Non Sampling Reason for Visit: Routine
#Is any exposed line constructed of ductile iron or other approved material? El ❑ ❑
Are water crossing and supports in good condition? 4 ❑ El El
#Is nght-of-way free of non-utility motorized traffic? ❑ ❑ El
Is line free of visible damage? r: ❑ 0 ❑
#Are there siphons in this system? ❑ ❑ El
If yes,are they maintained and documented?
Comment. This line is an aerial/creek crossing high priority line that is a 12-inch cast iron pipe with flanged
joints.
#6 PINE STR - Pine Street
Lines/Right-of-Ways/Aerie)Lines Yes No NA NE
Is right-of-way accessible for emergency? ® El El ❑
Is right-of-way free of sinkholes or depressions? El El El
Is line/right-of-way free of evidence of leakage'? ❑ ❑ El
#Are there areas of exposed line? El El El
#Is any exposed line constructed of ductile iron or other approved matenal? Y ❑ p ❑
Are water crossing and supports in good condition'? 3 El ❑ ❑
#Is right-of-way free of non-utility motorized traffic'? El p p El
Is line free of visible damage? El ❑ El
#Are there siphons in this system'? ❑ ❑ El
If yes,are they maintained and documented?
Comment: This line is an aerial/creek crossing high priority line that is an 8-inch ductile iron pipe with
flanged joints.
#9 HOLLAND RD - Holland
Lines/Right-of-Ways/Aerie)Lines Yes No NA NE
Is right-of-way accessible for emergency? ❑ ❑ ❑
Is right-of-way free of sinkholes or depressions? 41,. ❑ ❑ ❑ -
Is line/right-of-way free of evidence of leakage'? ® ❑ ❑ ❑
#Are there areas of exposed line? P1 ❑ ❑ ❑
#Is any exposed line constructed of ductile iron or other approved material'? ❑ ❑ p
Are water crossing and supports in good condition'? ❑ ❑ ❑
#Is right-of-way free of non-utility motorized traffic? ® ❑ ❑ ❑
Is line free of visible damage'? El El El ❑
#Are there siphons in this system'? ❑ El El
If yes,are they maintained and documented'?
Comment: This line is an aerial high priority line that is an 8-inch cast iron pipe with flanged joints.
#10 HOLLAND RD - Hollanc
Page 12

Permit: WQCS00193 Owner-Facility:Town of Fuquay-Varina
Inspection Date: 05/31/2018 Inspection Type:Collection System Inspect Non Sampling Reason for Visit: Routine
Lines/Right-of-ways/Aeriel Lines Yes No NA NE
Is right-of-way accessible for emergency? ❑ 0 0
Is right-of-way free of sinkholes or depressions? ® 0 0 ❑
Is line/right-of-way free of evidence of leakage? ; `t ❑ ❑ ❑
#Are there areas of exposed line? ❑ ❑ ❑
#Is any exposed line constructed of ductile iron or other approved material? ® ❑ 0 ❑
Are water crossing and supports in good condition? . 000
#Is right-of-way free of non-utility motorized traffic? 000
Is line free of visible damage? ❑ ❑ ❑
#Are there siphons in this system? ❑ ❑ ❑
If yes,are they maintained and documented?
Comment: This line is an aerial high priority line that is an 8-inch cast iron pipe with flanged joints.
#11 HOLLAND RD - Hollanc
Lines/Right-of-Ways/Aerie!Lines Yes No NA NE
Is right-of-way accessible for emergency? • . 000
Is nght-of-way free of sinkholes or depressions? ® ❑ ❑ ❑
Is line/right-of-way free of evidence of leakage? r 000
#Are there areas of exposed line? r 0 0 ❑
#Is any exposed line constructed of ductile iron or other approved material? ® ❑ ❑ ❑
Are water crossing and supports in good condition? a 000
#Is right-of-way free of non-utility motorized traffic? 000
Is line free of visible damage? El 000
#Are there siphons in this system? ❑ . 00
If yes,are they maintained and documented?
Comment. This line is an aerial high priority line that is an 18-inch ductile iron pipe with mechanical joints.
Page. 13

4 1 r 1
Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G.0201
Permittee Owner/Officer Name:
Mailing Address:
City: State: Zip: - Phone#:
Email address:
Signature: Date:
Facility Name: Permit#:
County:
SUBMIT A SEPARATE FORM FOR EACH.TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
Biological Collection Physical/Chemical Surface Irrigation Land Application
Operator in Responsible Charge(ORC)
Print Full Name: Email:
Certificate Type/Grade/Number: Work Phone#:
Signature: Date:
"I certify that I agree to my designation as the Operator in Responsible Charge for the facility noted.I understand and will abide by the rules
and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G.0204 and failing to do so can result in Disciplinary
Actions by the WatetPollution Control System Operators Certification Commission."
Back-Up Operator in Responsible Charge(I U ORC)
Print Full Name: Email:
Certificate Type/Grade/Number: Work Phone#:
Signature: Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted I understand and will abide by the
rules and regulations pertammg to the responsibilities of the BU ORC as set forth in 15A NCAC 08G.0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Email: certadminc ncdenr.gov
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 E Center Ave 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone]
Phone:[phone] Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
Revised 05-2015

WPCSOCC Operator Designation Form, cont
Facility Name: Permit#:
tack-Up-Operator in Responsible Charge(BU ORC)
Print Full Name: Email:
Certificate Type/-Grade/Number: — Work-Phone#:
Signature: Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted.I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G 0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
tack-Up Operator in Responsible Charge(BU ORC)
Print Full Name: Email:
Certificate Type/Grade/Number: Work Phone#:
Signature: Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted.I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G 0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Back-Up Operator in Responsible Charge(C U ORC)
Print Full Name: Email:
Certificate Type/Grade/Number: Work Phone#:
Signature: Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G.0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission"
..MMMMMMM 4 40.141.04•00•0 MMMMMM 13131•134.1413 MMMMMMMM IIM•24 MMMMM 4 4•00.10 MMMMMMMMMMMMMMMMMMMMMM 4 MMMMMMMMMMMMMMMMMMMMMMMMMMMMMMMM 01100 MMMMMMM oego•onolaraloonce•v
Back-Up Operator in Responsible Charge(BU ORC)
Print Full Name: Email:
Certificate Type/Grade/Number: Work Phone#:
Signature: Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G.0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 05-2015