Bypass Overflow Incident Report {48373}

BYPASS / OVERFLOW INCIDENT REPORT State Form 48373 (R7 / 4-16) Follow-up to Bypass report previously sent on: Indiana Department of Environmental Management Office of Water Quality INSTRUCTIONS: Complete all parts of this form and email signed copies to wwreports@idem.IN.gov. Submittal of this report will satisfy the Office of Water Quality (OWQ) telephone and written bypass/overflow reporting requirements of your NPDES permit. Please use and the second page of this form as necessary to identify separate locations caused by the same event. If you have any questions while filling out the report form, please contact Renee Repar at (317) 232-6770 or rrepar@idem.in.gov. To report a spill or if the release is resulting in a fish kill or other severe environmental damage, immediately report the release to the Emergency Response Section spill response line at: (317) 233-7745 or toll free within Indiana at (888) 233-7745. GENERAL INFORMATION (2) Mailing Address (reporting organization) (1) Facility Name (Organization) (3) County (4) NPDES Permit RELEASE INFORMATION (Location 1) (5) Outfall Number (6) Date (mm/dd/yy) and Time Release Began (7) Date (mm/dd/yy) and Time Release Stopped (8) Location of Release (streets address or Manhole, Lift Station, Force Main etc.) (9) Latitude (Deg Min Sec) (9) Longitude (Deg Min Sec) (10) Amount of Flow Released Check one: Estimated (13) Overflow Type (Select one.) AM AM PM PM (11) WWTP Flow During Release (12) WWTP Peak Design Flow Rate (Always provide a volume.) MGD MGD Actual Gallons (14) Describe any damage to aquatic life or receiving stream: Sanitary Sewer Overflow Treatment Bypass (at wastewater plant) Prohibited Combined Sewer Overflow Dry Weather Combined Sewer Overflow Combined Sewer System Release (15) Reason for Bypass / Overflow (Select one or more.) Construction Related Power Failure Equipment Failure Unknown Exceeded Max Capacity Precipitation Inches (17) Additional Description of the Bypass / Overflow Event: (16) System Component(s) (18) Description of the Area Impacted (Select one or more.) (Check all that apply.) Manhole Affected Private Property House Lateral Basement Backup Pipe Failure Occurred at Treatment Plant Pump Station Failure Reached Public Land Treatment Bypassed Reached Receiving Water Other Name of Receiving Water Impacted: Influent Structure Air Relief Valve Sewer Clean Out Describe Other: (in the box below) (19) Additional organizations notified by facility, if necessary (Select one or more.) IDEM Emergency Response Health Dept. DNR Fish and Wildlife Local Emergency Management Other: (20) Actions Taken to Prevent, Minimize, or Mitigate Damage including Clean-up and Treatment of Affected Area (Select one or more of the following, then add a written description.) Removed Blockage Repaired Pipe Repaired Pump Station Other Lime Clean-Up Debris (21) Resolution: Actions Taken or Planned to Prevent Recurrence (22) CERTIFICATION AND SIGNATURE I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations. (The area below is for a handwritten signature or an electronic substitute then fax or scan to PDF for emailing.) SIGNATURE: ___ ______________________________________________ Telephone Number Contact Email DATE (month, day, year):_ Date (month, day, year) / Time IDEM Notified Individual Making Report (printed) ____ AM PM American LegalNet, Inc. www.FormsWorkFlow.com BYPASS / OVERFLOW REPORT (Supplemental Locations) State Form 48373 (R7 / 4-16) Follow-up to Bypass report previously sent on: Indiana Department of Environmental Management Office of Water Quality (23) Complete all parts of each table for additional discharge locations caused by the same event as on the first page. For any locations identified in the NPDES permit, include the Outfall number for that location from the permit. RELEASE INFORMATION (Location 2) Date (mm/dd/yy) and Time Date (mm/dd/yy) and Time Location of Release (streets address or Latitude Longitude Release Began Release Stopped Manhole, Lift Station, Force Main etc.) (Deg Min Sec) (Deg Min Sec) AM AM PM PM Name of Receiving Water Impacted Description of the Area Impacted (Check all that apply.) Amount of Flow Released Estimated Actual Affected Private Property Basement Backup Reached Public Land Reached Receiving Water Gallons Outfall Number RELEASE INFORMATION (Location 3) Date (mm/dd/yy) and Time Date (mm/dd/yy) and Time Location of Release (streets address or Latitude Longitude Release Began Release Stopped Manhole, Lift Station, Force Main etc.) (Deg Min Sec) (Deg Min Sec) AM AM PM PM Name of Receiving Water Impacted Description of the Area Impacted (Check all that apply.) Amount of Flow Released Estimated Actual Affected Private Property Basement Backup Reached Public Land Reached Receiving Water Gallons Outfall Number RELEASE INFORMATION (Location 4) Date (mm/dd/yy) and Time Date (mm/dd/yy) and Time Location of Release (streets address or Latitude Longitude Release Began Release Stopped Manhole, Lift Station, Force Main etc.) (Deg Min Sec) (Deg Min Sec) AM AM PM PM Name of Receiving Water Impacted Description of the Area Impacted (Check all that apply.) Amount of Flow Released Estimated Actual Affected Private Property Basement Backup Reached Public Land Reached Receiving Water Gallons Outfall Number RELEASE INFORMATION (Location 5) Date (mm/dd/yy) and Time Date (mm/dd/yy) and Time Location of Release (streets address or Latitude Longitude Release Began Release Stopped Manhole, Lift Station, Force Main etc.) (Deg Min Sec) (Deg Min Sec) AM AM PM PM Name of Receiving Water Impacted Description of the Area Impacted (Check all that apply.) Amount of Flow Released Estimated Actual Affected Private Property Basement Backup Reached Public Land Reached Receiving Water Gallons Outfall Number RELEASE INFORMATION (Location 6) Date (mm/dd/yy) and Time Date (mm/dd/yy) and Time Location of Release (streets address or Latitude Longitude R