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In Front of #303 SSO 2016 ssoform•rev 01/2013 Massachusetts Department of Environmental Protection Bureau of Resource Protection —Watershed Permitting Program Sanitary Sewer Overflow (SSO)/Bypass Notification Form FOR DEI C. SSO Information (cont.) a.Idem fc Location: In front of#303 South Street, (Description of dischaye site orsite or South =tersection with Ham 5. Estimated SSO Volume at time of this Report: Pden St Unknown Method of Estimating Volume: 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 Blocks ❑ Other (Specify) ---� 7. Corrective Actions Taken: Blockage relieved by Jet roddjng in the Hampden Street Sewer Main. Impact Area cleaned and/or disinfected: Yes ❑ No Corrective Actions Completed: Jet Roddjng relieved the blockage, ❑ Yes No g street cleaned 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: 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)IBYPass Notification Form A. Reporting Facility 1. Facility Information Northam•ton De•artment of Public Works Reporting Sewer Authority 2. Authorized Representative Transmitting Form: Name La eis Donner Lae First 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: 4. Others notified(select all that apply): Conservation Commission �Division of Marine Fisheries Harbormaster ❑Shellfish Warden Downstream Drinking Water Supplier ❑ Watershed Association Beach Resource Manager ❑Other. C. SSO Information Paul first name 1212=08-2016 Date Geor e first name 12-06 Date Mere First Name 12-08-2016 Date dl.scaleia E-mail Address FOR DEP USE ONLY Tax Identification Number MA1 permit* 587-1670 Telephone No. ham etonma no Nietu�ski last name 7:45 Time Hardin last name 7:47 Time O'Lean Last Name 9:00 Time (specify) 12-07-2016 10_00 Time 1. SSO Discovered'. Date Routine inspection of trouble spots 1 1230 Time Date in Sanitary Sewer Manhole Pump Station 0 Other: (specif By: 2. SSO Stopped'. 3. SSO Discharge from: 0 Backup into Property 4. SSO Discharge to: ❑ Ground Surface(no release to surface water) (surface water) Mill River Diversion Canal (surface water) 0 Direct to Receiving Water Catch basin to Receiving Water 0 Backup into Property Basement form•rev.0112013 ©am ❑pm QX am ❑pm p 0 am © pm 0X am ❑pm Wastewater Over(lowiBypass or Sewage Backup Notification•Page 1 of 3 Drainage System Discharges to Mill River Diversion Canal Location of second Blockage Relieved by Jetting City of Northampton Public Nbrks Sanitary Sewer Overflow Incident,12107/2016 South St, Northampton,MA Massachusetts Department of Environmental Protection Bureau of Resource Protection—Watershed Permitting Program Sanitary Sewer Overflow (SSO)/Bypass Notification Form FOR DEP USE ONLY Tax Identlficabon 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 - - ,or those persons directly responsible for gathering the information,the information - fitted i to the best of my knowledge and belief,true,accurate,and complete. I am aware th ificant penalties for submittine - se information,including the possibility of fine a • i y'+Dome for knowing violations i � Date i m e lease keep 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 Ph Southeast Region Ph one: 978-694-3215 one: 508-946-2750 Central Region Western Region EPA Contact DEP 24-hour emergency sentar e•rev 0112013 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 Wastewater OverfiowiByPass or Sewage Backup Notification•Page 3 of 3