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Refer to the Sanitary Sewer Overflow and Backup Response Plan Binder for instructions for using this packet READ THIS FIRST In the event of a Sanitary Sewer Overflow Check here if you believe that fats, oils and/or grease (FOG) caused or contributed to the SSO After performing initial evaluation, contact (in order until someone is reached): Environmental Services: 577.6200 (bus hrs) 652.3334 (cell) 577.6200 (after hrs) Wastewater Supervisor: 577.6234 (bus hrs) 652.9506 (cell) 577.6200 (after hrs) Wastewater Supervisor: 577.6287 (bus hrs) 652.7425 (cell) 577.6200 (after hrs) Wastewater Supervisor: 577.6239 (bus hrs) 652.9069 (cell) 577.6200 (after hrs) Wastewater Manager: 577.6222 (bus hrs) 652.0326 (cell) 577.6200 (after hrs) Senior Operator on Duty: 577.6225 Pvt 607 For any media requests: Public Information Analyst [PHONE REDACTED] (office) [PHONE REDACTED] (cell) City of Modesto Collections Staff 1st: Open this envelope. 2nd: Follow the instructions on the card: “Responding to a Sanitary Sewer Overflow” 3rd: Reference the Field Binder as necessary 4th: Complete the Chain of Custody record (right) and forward this packet to the Collections System Supervisor Chain of Custody Instructions Print Name: Initial: Date: Time: Collections System Supervisor 1st: Open this envelope. Review forms. 2nd: Forward the Regulatory Notifications Packet to the person authorized to make required notifications (enter name and title of that individual to the right). 3rd: Archive all documentation related to this incident in accordance with City of Modesto procedures. Print Name: Initial: Date: Time: Regulatory Notifications Packet given to: Name: Title: ---PAGE BREAK--- City of Modesto SSO/Backup Response Plan OP Sanitary Sewer Overflow Packet: Table of Contents Form Form Number Instructions and Chain of Custody envelope label Responding to a Sanitary Sewer Overflow OP-1 Sewer Overflow Report -2 Sewer Spill Reference Guide pamphlet Public Posting n/a Door Hanger n/a ---PAGE BREAK--- City of Modesto SSO/Backup Response Plan OP-2 Side A SSO Packet: Sanitary Sewer Overflow Report This Report is (check one): Preliminary Final Revised Final A. SPILL LOCATION Spill Location Name: Street Name and Number: Street Direction N, S, W, NE, SW, etc.): Nearest Cross Street City: Zip Code: County: Stanislaus Spill Location Description: Location 2: Street Name and Number: Location 3: Street Name and Number: Use separate sheet for more than three locations B. SPILL DESCRIPTION Spill Appearance Point: Building/Structure Force Main Gravity Sewer Other Sewer System Structure Pump Station Manhole- Structure ID#: Other (specify): Did the spill reach a gravity storm drain? Yes No If the spill reached a gravity storm drain, was it fully captured and returned to the Sanitary Sewer? Yes No If spill was NOT fully captured and returned to sanitary sewer, does gravity storm drain discharge to a dedicated storm water or ground water infiltration basin (i.e. Rockwell or retention basin)? Yes No Was this spill from a private service lateral? Yes No If YES, name of responsible party: Final Spill Destination: Beach Building structure Other paved surface Storm drain Street/curb& gutter Surface water Unpaved surface Other (specify): Estimated spill volume (in gallons): Method calculated: Est. volume of SSO recovered (gal): Were photos taken? No Yes – how many? Estimated volume of spill reaching surface water, drainage channel, or not recovered from a storm drain (gal): Note: Notify Supervisor immediately if the spill reached a gravity storm drainage system C. SPILL OCCURRING TIME SSO Reported to (who received call): SSO Reported by (who called): Phone: Estimated spill start date and time: Date and time spill reported to sewer crew: Date and time sewer crew arrived: Estimated spill end date and time: Weather conditions prior 72 hours: Sunny Weather Cloudy Weather Measurable Rain Rain for Several Days D. CAUSE OF SPILL – PLEASE CHECK “PRIMARY” CAUSE OF SSO SSO cause (check”Primary” cause): Debris/Blockage Flow exceeded capacity Grease Operator error Roots Pipe problem/failure Pump station failure Rainfall exceeded design Vandalism Inflow/infiltration Animal carcass Electrical power failure Bypass Debris from laterals Construction Debris Other (specify): If SSO is caused by a private service lateral, please specify: This is the owner tenant manager Property contact: Contact telephone: If SSO is caused by wet weather, choose size of storm: 1-yr 2-yr 5-yr 10-yr 50-yr 100-yr >100-yr Unknown Diameter (in inches) of pipe at point of blockage/spill cause (if applicable): Sewer pipe material at point of blockage/spill cause (if applicable): Description of terrain surrounding point of blockage/spill cause: Flat Mixed Steep E. SPILL RESPONSE Spill response activities (check all that apply): Cleaned up Contained all/portion of spill TV inspection Restored flow Returned all/portion of spill to sanitary sewer Other (specify): Spill response completed (date & time): Name of impacted waters (if applicable): Visual inspection result of impacted waters (if applicable): Any fish killed? Yes No Any ongoing investigation? Yes No Name of impacted beach (if applicable): Were health warnings posted? Yes No Health warning/beach closure posting/details: Were samples of impacted waters collected? Yes No If YES, select the analyses: DO Ammonia Bacti Other Spill Volume Estimated by: Report Completed by: Report Verified by: ---PAGE BREAK--- City of Modesto SSO/Backup Response Plan OP-2 Side B SSO Packet: Sanitary Sewer Overflow Report F. NOTIFICATION DETAILS CALEMA contacted date and time (if applicable): CALEMA Control Number (if applicable): Spoke to: Report by: Immediately contact one of the individuals on the list below and request that they notify CAL-EMA (800) 852-7550 within two hours of the time City staff become aware of: An SSO with an estimated volume < 1,000 gallons, AND Discharged to surface waters or in a location where it will probably will be discharged to surface waters PERSON CELL PHONE BUSINESS HOURS AFTER HOURS Regulatory Compliance Inspector (on call) See Standby Roster [PHONE REDACTED] [PHONE REDACTED] Regulatory Compliance Adminstrator [PHONE REDACTED] [PHONE REDACTED] [PHONE REDACTED] Wastewater Collections Supervisor [PHONE REDACTED] [PHONE REDACTED] [PHONE REDACTED] Wastewater Collections Supervisor [PHONE REDACTED] [PHONE REDACTED] [PHONE REDACTED] Stormwater Collections Supervisor [PHONE REDACTED] [PHONE REDACTED] [PHONE REDACTED] Wastewater Collections Manager [PHONE REDACTED] [PHONE REDACTED] [PHONE REDACTED] Deputy Director [PHONE REDACTED] [PHONE REDACTED] [PHONE REDACTED] Primary Reporting Summary Refer to Side B for contact information, timeframes and reporting procedures If the backup or SSO is: Required action or contact: 50,000 gals or greater, and Results in a discharge to surface water or Discharged to a positive storm drain (not a rockwell or a detention basin) that was not fully recovered California Emergency Management Agency (CalEMA) (800) 852-7550 Within 2 hours (made by Supervisor) Submit draft report into CIWQS within three business days Certify CIWQS report within 15 days Conduct water quality monitoring within 48 hours Submit technical report within 45 days 1,000 gal or greater, and Results in a discharge to surface water or Discharged to a positive storm drain (not a rockwell or a detention basin) that was not fully recovered California Emergency Management Agency (CalEMA) (800) 852-7550 Within 2 hours Submit draft report into CIWQS within three business days Certify CIWQS report within 15 days LESS than 1000 gal, but Reached surface water, or Discharged to a positive storm drain (is not a rockwell or a detention basin) that was not fully recovered Submit draft report into CIWQS within three business days Certify CIWQS report within 15 days 1,000 gals or greater, and NOT discharged to surface water or is not fully recovered, or Any discharge to rockwells and detention basins Submit draft report into CIWQS within three business days Certify CIWQS report within 15 days LESS than 1,000 gals, AND NOT discharged to surface water or fully recovered, or Any discharge to rockwells and detention basins Submit certified report into CIWQS within 30 calendar days of the end of the month in which SSO occurred Was caused by problems with a private service lateral Optional reporting into CIWQS Place completed form in Sewer Backup Envelope and follow routing instructions.