SANITARY SEWER OVERFLOW EVENT REPORTING FORM

NOTE: This form is to be used to document written notification of a sanitary sewer overflow event or sewage release within five days of becoming aware of the event.

Permittee Name:

Town of Sylvania

Permit Number:

N/A (Collection System Only)

Facility Name:

Sylvania Wastewater Collection System

County:

DeKalb

Date/Time SSO Began:

11/3/2008

Date/Time SSO Stopped:

3/31/2009 1:30 PM

Estimated Volume Discharged:

400,000

gallons

(Mandatory)

Estimated Volume is:

(   ) <1,000gal

(   ) >1,000gal

(   ) >10,000gal

(X) >100,000gal

(   ) >1,000,000gal

Was Department verbally notified within 24 hours?

(X) Yes

(   ) No

Date/Time of Notification:

4/1/2009 9:30 AM

Person that verbally notified Department:

Mike Kling, City Manager

Phone Number:

(256) 638-2604

Did you contact the SSO hotline?

(X) Yes

(   ) No

Indicate source of discharge event:

(   ) manhole

(   ) lift station

(   ) broken line

(   ) cleanout

(   ) treatment plant

(X) other (describe):

Open Valve

Location of discharge (street address, etc.):

Intersection of County Road 91 and County Road 47 on the east side of the

creek crossing on County Road 91

Known or suspected cause of the discharge:

Installed isolation plug valve was left open after the pump station conversion

from an effluent pump station to a raw wastewater pump station serving the Housing Authority

Ultimate destination of discharge:

(   ) ground absorbed

(X) creek or river (provide name):

UT to South Sauty Creek

(   ) storm drain

(   ) drainage ditch

(   ) other (describe):

Monitoring of the receiving water is:

(   )     complete

(   )     ongoing

Describe corrective actions taken, plans to eliminate future discharges, and actions or plans to mitigate impacts to the environment

and/or public health (attach additional sheets if necessary):

Plug valve closed to stop discharge.  Line will be excavated and

plugged to prevent future discharge in case of accidential valve opening.

Indicate efforts to notify public (check all that apply):

(   ) press release

(X) other (describe):

Public Notice posted in Town Hall

(   ) placement of signs

(   ) notice not required, because:

Indicate other officials notified (check all that apply):

(X) county health department

(   ) other (describe):

(   ) notice not required, because:

Were any public water supply intake locations effected?

(X) No

(   ) Yes

If yes, who was notified?

Mike Kling, City Manager

Name/Title of Facility Representative

Signature of Responsible Official

Date

(If > 10,000 gal)

I certify that I have personally examined and am familiar with the information submitted herein.  Based on my inquiry of those individuals immediately responsible for obtaining the information, I believe the submitted information to be true, accurate, and complete.  I am aware that there are significant penalties for knowingly submitting false information, including the possibility of fine and imprisonment.

ONE COPY OF A USGS QUAD SHEET OR OTHER GEOGRAPHICALLY REFERENCED MAP MUST BE ATTACHED SHOWING THE EXACT LOCATION OF ALL DISCHARGES GREATER THAN 10,000 GALLONS.