49 Sanitary Sewer Overflow 2012 t
Massachusetts Department of Environmental Protection
Bureau of Resource Protection—Watershed Permitting Program
Sanitary Sewer Overflow (SSO)IBypass
Notification Form
FOR DEP USE ONLY
Tax Identification Number
A. General Information
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Facility Information
MAO101818
a. Reporting Facility Pend Number
Northampton Department of Public Works -- ---
b. Name of Collection SystemfTreabnent Works - —
Authorized Representative filing this notification form:
Edward ____ .Huntley
413-587-1570 ..__.
a. Firs(Name b. Last Name — C. Telephone(10)
Director of Public Works nhuntley @nohodow.org
d. The or Authorized Representative e. E-mail Address of Authorized Representative
Event Report Information
a. Are you reporting: ® I. Unanticipated SSO or Bypass ❑2.Anticipated SSO or Bypass
B. Phone Notifications Made, if any:
Kurt
_.. __.... .__
a. first name
1. MassDEP person contacted:
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):
❑
10/03/2012
Boisjolie
b. last name
c Date (mrnlddryyyy) Time.
04:30
d.hhmm
❑e.am
f pm
Harding
b. last name
10/03/2012 04:30 ❑e.am
Time: d. nn:mro ®f.pm
C. Date(muMddryyn)
❑a. Conservation Commission ❑b. Board of Health
C.Harbormaster ❑ d.Downstream WS ❑ e.Watershed Association ❑f. Shellfish Warden
❑g.Other: h. Specify
C. General Information About SSO/Unanticipated Bypass
10/0312012_._. _.... 2:30
1. When did the event occur? Time: b hh:mm
a Date(mmltldlyyyy)
49 Murphy Terrace _.. 42-19-52
2. Location of event: a.Number and Street(or closest address) b.latitude
3. Estimated volume of overflow discharge at the time of this report:
150 gallons
a. Estimated Volume:
b. Method of estimating volume:
4. Where did the overflow discharge to?(e.g.,
surface water, ground)
49 Murphy Terrace 20121003_SSO Noll(
1-2 inches on basement floor
Basement
❑c.am
d pm
72-38-37
c longitude
0712010 Wastewater Overflow/Bypass or Sewage Backup Notification'Page 1 of 3
P e
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
❑b snowmelt ❑c. high groundwater
❑a. insufficient capacity e. sewer system blockage or collapse
❑r pump/lift station failure
Grease
❑ h.Other: 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 ❑b repaired pump/lift ❑C. repaired service
station connection
blockage ❑t. backflow prevention
❑d. drained or pumped ❑e. disinfection treatment device installed
sewage out of building
❑g. Other:
❑g. treatment facility equipment failure
h. SpeNty
D. General Information About Anticipated Bypass
Time.
a. Date(mmrddlyyyY)
e.Number and Street(or closest address)
b.latitude
1. When will the bypass occur?
2. Where will the bypass occur?
b. hh:mm
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 ❑b. snowmelt
❑d. insufficient ❑e. sewer system blockage or collapse
capacity
❑t. pump/lift ❑g. treatment facility equipment failure
station failure
❑g.Other % Specify
5. Will an SSO occur during the bypass? ❑ a. Yes
a.l. Where will SSO discharge to?
A 5-day follow-up report is required for the SSO.
❑b No
49 Murphy Terrace 20121003_SSO Notification•rev.07/2010
❑cam
❑d.pm
c. longitude
❑C. high groundwater
Wastewater Over low/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:
F. 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. I am
aware that there are significant penalties for submitting false information, including the possibility of
fine and imprisonment for knowing violations.
---rdiefadf-21s4PC /10
1. Signature of Authorized Representative
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:
Phone: 978-694-3215 Fax: 978-694-3499
Fax: 508-947-6557
Fax. 508-792-7621
Fax: 413-784-1149
Northeast Region
Southeast Region
Central Region
Western Region
EPA Contact
DEP 24-hour
emergency
Phone: 508-946-2750
Phone: 508-792-7650
Phone: 413-784-1100
Phone: 617-918-1766
Phone 888-304-1133
49 Murphy Terrace 20121003 SSO Notification•rev.07/2010 Wastewater Overflow/Bypass or Sewage Backup Notification•Page 3 of 3
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49 Murphy Terrace SSO, October 3, 2012
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