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15 SSO 2016 Massachusetts Department of Environmental Protection Bureau of Resource Protection —Watershed Permitting Program Sanitary Sewer Overflow (SSO)/Bypass Notification Form FOR DEP USE ONLY Tax Identification Number C. SSO Information (cont.) Location: 15 Nonotuck St (Description of discharge site or closest address) 5. Estimated SSO Volume at time of this Report: 50 gallons Method of Estimating Volume: "1" in basement 6. Cause of SSO Event: ❑ Rain Event ❑ Pump Station Failure ❑ Insufficient Capacity in System ❑ Treatment Unit failure ® Sewer System Blockage: ❑ Pipe Collapse © Root Intrusion ❑ Grease Blockage ❑ Other: (Specify) 7. Corrective Actions Taken: Blockage relieved by Jet rodding in the main. Impact Area cleaned and/or disinfected: E Yes ❑ No Servicemaster called by owner Corrective Actions Completed: ❑ Yes ❑ No D. Comments/Attachments/Follow-up I wish to provide(select all that apply): IX1 Attachment ❑ Additional comments below. ❑ No additional comments or attachments Additional comments and planned actions: Sewer main to be treated for roots ssoform•rev.01/2013 Wastewater Overflow/Bypass or Sewage Backup Notification•Page 2 of 3 nportant:When Iling out forms n the computer, se only the tab ey to move your ursor-do not se the return See DEP iegional Office elephone and ax numbers at he end of this Massachusetts Department of Environmental Protection Bureau of Resource Protection —Watershed Permitting Program Sanitary Sewer Overflow (SSO)/Bypass Notification Form FOR DEP USE ONLY Tax Identification Number A. Reporting Facility 1. Facility Information Northampton Department of Public Works Reporting Sewer Authority 2. Authorized Representative Transmitting Form: Donna LaScaleia First Name Last Name Director of Public Works Title B. Phone Notifications: 1. MassDEP staff contacted: Date/Time contacted: 2. EPA staff contacted: Date/Time EPA contacted. 3. Board of Health contacted: Date/Time contacted: MA101818 Permit* (413) 587-1570 Telephone No. dlascaleia( northamptonma.gov E-mail Address Paul first name 11-7-2016 Date George first name 11-6-2016 Date Meredith First Name 11-8-2016 Date 4. Others notified(select all that apply); ❑ Harbormaster ❑ Shellfish Warden ❑ Downstream Drinking Water Supplier ❑ Beach Resource Manager ❑Other: Nietupski last name 8:00 Time Harding last name 11:00 Time O'Leary Last Name 2:45 Time ❑ Conservation Commission ❑ Division of Marine Fisheries ❑ Watershed Association am al Pm ❑am ©pm ❑am El pm (specify) C. SSO Information 1. SSO Discovered: Call from dispatch By: 2. SSO Stopped: 11-6-2016 Date 10:00 Time ❑am © pm 11-6-2016 Date 3. SSO Discharge from: ® Sanitary Sewer Manhole 10:45 Time ❑ Pump Station Backup into Property ❑ Other: (specify) ❑am IX7 pm 4. SSO Discharge to: ® Ground Surface(no release to surface water) ❑ Direct to Receiving Water ❑ Catch basin to Receiving Water Backup into Property Basement (surface water) (surface water) ssoform•rev.01/2013 Wastewater OveMOW/Bypass or Sewage Backup Notification•Page 1 of 3 • 0 •••••';'7,,,„ Location of small amount of discharge from SMH 0 Location of Root Blockage in Sewer Main.removed by jetting Backup in Household Basement • 0 224 OCity of Northarnpton Public Vflake Sanitary Sewer Overflow Incident,11/06/2016 15 Nonotuck St, Northampton,MA Massachusetts Department of Environmental Protection Bureau of Resource Protection—Watershed Permitting Program Sanitary Sewer Overflow (SSO)IBypass Notification Form FOR DEP USE ONLY Tax wastmalbn nu ear E. Certification Statement 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 property 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 and imprisonments ng violations. Signature otAsnonud Repreaenteaw f01Z. /in. JJ%'& 2n4 Se,p US IA Date signed Please keep a copy of this report for your records.When submitting additional information,include the MassDEP Incident Number from this report. MassDEP Regional Office and EPA Telephone and Fax Numbers: Northeast Region Southeast Region Central Region Westem Region EPA Contact DEP 24-hour emergency esofern•rev.01/20 Phone: 978-6943215 Phone: 508-946.2750 Phone: 508-792-7850 Phone: 413-784-1100 Phone: 617-918-1870 Phone: 888-304-1133 Fax: 978-894-3499 Fax: 508-9476557 Fax: 508-792-7621 Fax: 413-7841149 Fax:817.918-0870 Wastewater Overflow/Bypass or Sewage Backup NolLaon•Page 8 of 3