52 Sanitary Sewer OverflowBypass Notification Form Important When
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Massachusetts Department of Environmental Protection
Bureau of Resource Protection —Watershed Permitting Program
Sanitary Sewer Overflow (SSO)IBypass
Notification Form
FOR DEP USE ONLY
Tax Ideneication Number
A. General Information
1. Facility Information
MA0101818
a Reporting Facility Permit Number
Northampton Department of Public Works
b Name of Collection System/Treatment Works
2. Authorized Representative filing this notification form:
Edward Huntley
a First Name b. Last Name
Director of Public Works
d. Title of Authorized Representative
413-587-1570
c. Telephone(10)
nhuntley@nohodpw.org
e. E-mail Address of Authorized Representative
3. Event Report Information
a. Are you reporting: ® 1. Unanticipated SSO or Bypass ❑ 2.Anticipated SSO or Bypass
B. Phone Notifications Made, if any:
1. MassDEP person contacted: Kurt _.
e first name
Date/Time MassDEP contacted by phone:
George
a. first name
2. EPA person contacted:
Date/Time EPA contacted by phone:
3. Others notified(select all that apply):
Boisjolie
b last name
07/20/2012 Time:
c. Date (mmrddfyyyy)
07/20/2012
_- -
c Date(mMtldtyyyy)
Harding_
b. last name
Time:
01:15
d.hh'.mm
01:15
a-hh:mm
❑e am
®f.pm
❑e.am
❑f pm
❑ a Conservation Commission b. Board of Health
❑ 0.Harbormaster ❑ d. Downstream WS ❑ e.Watershed Association ❑r Shellfish Warden
❑g.Other:
h.Specify
C. General Information About SSO/Unanticipated Bypass
07/10/2012 10:00 ❑ c am
1. When did the event occur? Time:
a. Date(mmfdayyyy — b. hrrmm 2 d.pm
2. Location of event:
52 Carolyn Street 42-20-47 72-39-58
a.Number and Street(or closest address) b latitude c.longitude
3. Estimated volume of overflow discharge at the time of this report:
< 5 gallons
b Method of estimating volume:
Less than volume of sink
4. Where did the overflow discharge to?(e.g., Sink in the basement
surface water, ground)
a. Estimated Volume:
52 Carolyn 20120710_SSO Notification•rev.07/2010
Wastewater Overflow/Bypass or Sewage Backup Notifica tion•Page 1 of 3
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. General Information About SSO/Unanticipated Bypass (cont.)
5. Identify causes of/reasons for the event: (select all that apply)
❑ a rain
❑d. insufficient capacity
❑ t. pump/lift station failure
❑ h.Other:
❑b. snowmeit
❑ c high groundwater
e. sewer system blockage or collapse
❑g. treatment facility equipment failure
Possible Roots
i.Specify
6. Have corrective actions been completed? a. Yes ❑ b. No ❑c No Action Required
7. Corrective measures taken(select all that apply, or use Section E to attach additional comments):
®a.repaired sewer/cleared
blockage
❑d. drained or pumped
sewage out of building
❑g. Other h. Specify
❑ b.repaired pump/lift
station
❑e. disinfection treatment
❑c. repaired service
connection
❑f. backflow prevention
device installed
D. General Information About Anticipated Bypass
1. When will the bypass occur? a. Date(mrd/WYY) Time.
md
2. Where will the bypass occur? a. Number and Street(or closest address)
3. Estimated volume of overflow discharge at the time of this report:
a. Estimated volume:
b. Method of estimating volume:
4. Identify causes of/reasons for the event: (select all that apply)
❑a. rain
❑d. insufficient
capacity
❑ r pump/lift
station failure
b hhmm
b latitude
❑c.am
❑d pm
c longitude
❑b. snowmelt ❑ c. high groundwater
❑e. sewer system blockage or collapse
❑g. treatment facility equipment failure
❑g Other: i. Specify
5. Will an SSO occur during the bypass? ❑a. Yes
at Where will SSO discharge to? - -
A 5-day follow-up report is required for the SSO.
0 b.No
52 Carolyn 20120710_SSO Not
ion•rev.07/2010 Wastewater Overflow/Bypass or Sewage Backup Notification•Page 2 of 3
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
D. General Information About Anticipated Bypass (cont.)
Please be advised that if the anticipated bypass detailed above results in an unanticipated
bypass+SSO, MassDEP must be notified within 24 hours and a new form completed.
Please provide comments in Section E detailing the preventive measures to be taken during the event.
E. Comments/Attachments/Follow-up
I wish to provide(select all that apply):
® 1 Attachment® 2. Additional comments below: ❑ 3. No additional comments or attachments
2a. Additional comments and planned actions:
DPW staff investigated and found the sewer manhole in front of 52 Carolyn full and a plumber from
Fletcher's had earlier found no blockage in the sewer service for 52 Carolyn. DPW staff jet rodded the
cross country sewer main with the flow toward Claire Ave and at approximately 65 feet encountered a
blockage and broke through it, relieving the back up. Possible root problem in this area to be
investigated and corrected.
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
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.1 am
aware that there are significant penalties for submitting false information, including the possibility of
fine and imprisonment for knowing violations.
7
1.Signature orAWhonz tl Representative 2 D Si ed
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
Western Region
EPA Contact
DEP 24-hour
emergency
Phone: 978-694-3215
Phone: 508-946-2750
Phone: 508-792-7650
Phone: 413-784-1100
Phone: 617-918-1766
Phone: 888-304-1133
52 Carolyn 20120710 SSO Notification•rev.07/2010
Fax: 978-694-3499
Fax: 508-947-6557
Fax: 508-792-7621
Fax: 413-784-1149
Wastewater Overflow/Bypass or Sewage Backup Notification•Page 3 of 3
52 Carolyn Street SSO, July 10, 2012
52 Carolyn St
SSO Location
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