WQ0004910_Report_20180731

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Dw.R
Collection System Sanitary Sewer Overflow Reporting Form
Division of Water Resources
Form CS-SSO
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•{�✓4 O c14? QCS#if active, otherwise use WQCSD#) VVQ O49/�
ty ,+ '�/V c1 fCYvrt�
Facile .{i(faGC/�Qh4f�' /�'G Gn Sy-St/incident#. f Owner: 1 WI ,
Region• City �Iariki?4 County: A/0 j-'t-ham')t
Source of SSO (check applicable): Sanitary Sewer I 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#. 2_8 @ NG
Latitude (degrees/minute/second). Longitude (degrees/minute/second).
Incident Started Dt 7-024-V61 Time• G'30 A' Incident End Dt 9,`'Io 41'! Time. / "T4
(mm-dd-yyyy) (hh:mm)AM/PM (mm-dd-yyyy) 7_21}-/6 (hh:mm)AM/PM
Estimated volume of the SSO: 3'c2O gallons Estimated Duration (round to nearest hour) 3 hour(s)
Describe how the volume was determined. L 5 7/YIate. RSCS I
Weather conditions during the SSO event Rael4.'6' "gat t11 sD•®cApo
JUL
3 ®W�
Did the SSO reach surface waters? 571-Yes No I Unknown j 2018
Volume reaching surface waters. 500 gallons Surface water name. Pe •mer eS Ut
Did the SSO result in a fish kill? I I Yes I til No I I Unknown tn0`SeCtjp1
If Yes,what is the estimated number of fish killed?
SPECIFIC cause(s) of the SSO.
;Severe Natural Conditions I Grease I (RootsI J✓Inflow& Infiltration
I !Pump Station Equipment Failure I I Power Outage Vandalism I Debris in line I (Pipe Failure (Break)
Other(Please explain in Part II)
24-hour verbal notification(name of person contacted):
IDWR I (Emergency Management Date(mm-dd-yyy)•") ;j4 /'Time: (hh:mm AM/PM)2 :;2r P/r
Per G.S. 143-215.1 C(b), the owner or operator of any wastewater collection system shall: try Kre f5 eY'
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 I1 IS COMPLETED,A SIGNATURE IS REQUIRED SEE PAGE 13
Form CS-SSO Page 1

0
Inflow and Infiltration
Are you under an SOC (Special Order by Consent)or do you have a schedule I I Yes No NA NE
in any permit that addresses I/1?
Explain if Yes:
What corrective actions have been taken to reduce or eliminate I & I related overflows this spill location
within the last year? L;'n'- re-Fat r
Has there been any flow studies to determine I/I problems in the Yes I I No I INA NE
collection system at the SSO location? — 1
If Yes,when was the study completed and what actions did it recommend?
Has the line been smoke tested or videoed within the past year? Yes No I INA NE
If Yes,when and what actions are necessary and the status of such actions
Are there I/I related projects in your Capital Improvement Plan? I I Yes No [ IvNA I I NE
If Yes, explain.
Have there been any grant or loan applications for I/I reduction projects? Yes I I No I INA I I NE
If Yes, explain
Do you suspect any major sources of inflow or cross connections I I Yes o I INA I I NE
with storm sewers?
If Yes, explain
Have all lines contacting surface waters in the SSO location and upstream Yes No NA I j NE
been inspected recently?
If Yes, explain.
What other corrective actions are planned to prevent future I/I related SSOs at this location?
Comments: 4/01- arc( K// j?"ver w A5� 5, i d "ecvfi e a rctvl� 1G Sl/J Iih2
4t/in ye/Ver p/ f-eJab Mme n4an he/es Ye r e- rev()fe z' e s etv /1 tile.
Form CS-SSO Page 6

System Visitation,
ORC Yes
P/' E L0y1± r
Backup Yes
tUhLeIe/-
Name.
Certification Number
Date visited: '2 - V I
Time visited: /0 "
How was the SSO remediated (i./e. Stopped and cleaned up)? 7e5/
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: M- 1-a.c9/ Date: 7-02��2S
Signature: /lif •,• �' Title: Or 1 VCS
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