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89 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 A. Reporting Facility octant:When g out forms 1. Facility Information he computer. only the tab Northampton Department of Public Works to move your Reporting Sewer Authority or-do not the r tum 2. Authorized Representative Transmitting Form: UI Donna LaScaleia (413) 587-1570 F rst Name Last Name Telephone No Director of Public Works dlascaleia . northam.tonma..ov A T tle E-mail Addre B. Phone Notifications: MA101818 Permit •DEP rional Office phone and numbers at end of this 1. MassDEP staff contacted: Date/Time contacted: 2. EPA staff contacted: Date/Time EPA contacted: 3. Board of Health contacted: Date/Time contacted: Paul Nietupski first name last name 11-3-2016 2:40 Date Time George Harding first name last name 11-3-2016 2:50 Date Time Meredith O'Leary Frst Name Last Name 11 4 2016 2:00 Date Time 4. Others notified(select all that apply); ❑Conservation Commission ❑ Harbormaster ❑ Shellfish Warden ❑ Division of Marine Fisheries ❑ Downstream Drinking Water Supplier ❑ Watershed Association ❑ Beach Resource Manager ❑ Other: (specify) F3 am El pm ❑am ®pm ❑am I3 pm C. SSO Information 1. SSO Discovered: Call from owner. By: 11-3-2016 11:30 Date Time am ❑pm 2. SSO Stopped: 11-3-2016 Date 3. SSO Discharge from: ❑ Sanitary Sewer Manhole 12:45 Time ❑ Pump Station Backup into Property ❑ Other: (specify) ❑ am i3 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 t3 soform•rev.01/2013 (surface water) (surface water) Wastewater Overflow/Bypass or Sewage Backup Notificafion•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. SSO Information (cont.) 89 Massassoit Street Location: (Description of discharge site or closest address) 5 Estimated SSO Volume at time of this Report: Method of Estimating Volume. 6. Cause of SSO Event: 200 gallons 1" in basement ❑ Rain Event ❑ Pump Station Failure ❑ Insufficient Capacity in System ❑ Treatment Unit failure al Sewer System Blockage: ❑ Pipe Collapse ❑ Root Intrusion ❑ Grease Blockage Sediment and Rags(disposable wipes) in main and service line from house © Other. (Specify) 7. Corrective Actions Taken: Blockage relieved by Jet rodding in the main and Roto Rooter in the lateral. Impact Area cleaned and/or disinfected: ❑ Yes ❑ No Corrective Actions Completed: ❑ Yes ❑ No Sewer main to be inspected, follow up cleaning and vectoring. D. Comments/Attachments/Follow-up I wish to provide(select all that apply): ® Attachment ❑ Additional comments below: ❑ No additional comments or attachments Additional comments and planned actions: It appears that the blockagees in the sewer main and the lateral were caused by a combination of sediment buildup and disposable wipes. :soform•rev.01/2013 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 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 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 forgathering the information,the information sub ••-• ,to the best of my knowledge and belief,true,accurate,and complete. I am aware tha e are si nificant penalties for submitting false information,including the possibility of fine ar '1%L'Dome for knowing violations. ure of Authonz• Representative 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 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: 617-918-1870 Phone: 888-304-1133 Fax: 978-694-3499 Fax 508-947-6557 Fax 508-792-7621 Fax: 413-784-1149 Fax:617-918-0870 ssofonn•rev.0112013 Wastewater Overflow/Bypass or Sewage Backup Notification•Page 3 of 3 eCity of Northampton Public Works Sanitary Sewer Overflow Incident 11/312016 89 Massassoit St, Northampton,MA