READ THIS FIRST. Check here if you believe that fats, oils and/or grease (FOG) caused or contributed to the SSO. Date: Time: Title:

Transcription

1 READ THIS FIRST In the event of a Sanitary Sewer Overflow Check here if you believe that fats, oils and/or grease (FOG) caused or contributed to the SSO Address: Date: 1 st : Open this envelope. Instructions Collections Crew 2 nd : Follow the instructions on the card OP-1: Responding to a Sanitary Sewer Overflow 3 rd : Immediately contact Assistant Wastewater Superintendent to begin 2-hour notification process for any Category 1 SSO. Print Name: Initial: Date: Time: Chain of Custody 4 th : Reference the Field Reference Guide as necessary 5 th : Put everything back in this Sewer Overflow Envelope: camera (if used), SSO Report, any additional notes/documentation. 6 th : Document the service call according to City procedures. Assistant Wastewater Superintendent or Designee 1 st : Open this envelope. Review forms/documentation. 2 nd : Open the Regulatory Notifications Packet (inside this envelope) and make the required notifications. 3 rd : Send camera out for processing (if applicable) or copy digital images to cd and place in this Sewer Overflow Envelope. 4 th : File this completed Sewer Overflow Envelope in accordance with City policy. Print Name: Initial: Date: Time: Regulatory Notifications Packet given to: Name: Title: For any media requests, immediately contact the Assistant Wastewater Superintendent or designee at City of Pacifica Sanitary Sewer Overflow and Backup Response Plan

2 Sanitary Sewer Overflow Response Packet Table of Contents OP Form Form Number Instructions and Chain of Custody... envelope label Responding to a Sanitary Sewer Overflow... OP-1 Sewer Overflow Report Collection System Failure Analysis Form ICOM3 Service Call Form Regulatory Notifications Packet Instructions... envelope Guide to Reporting to Regulatory Authorities... RN-1 Fax Reporting Form: To Local Health Agency Sewer Spill Reference Guide... pamphlet Public Posting... n/a Door Hanger... n/a For pre-assembled packets contact DKF Solutions Group at or losscontrol@sbcglobal.net

3 Sanitary Sewer Overflow Response Packet Sanitary Sewer Overflow Report OP-2 Side A INSTRUCTIONS: Complete all items EXCEPT those that are shaded gray Spill Category (check one): Category 1 Category 2 A. SPILL LOCATION Spill Location Name: Latitude Coordinates: Street Name and Number: Longitude Coordinates: Nearest Cross Street City: Zip Code: County: San Mateo Spill Location Description: B. SPILL DESCRIPTION Spill Appearance Point: Building/Structure Force Main Gravity Sewer Other Sewer System Structure (i.e. cleanout) Pump Station Manhole- Structure ID#: Other (specify): Did the spill reach a drainage channel and/or surface water? Yes (Category 1) No If the spill reached a storm sewer, was it fully captured and returned to the Sanitary Sewer? Yes No (Category 1) Was this spill from a private lateral? Yes No If YES, name of responsible party: Final Spill Destination: Beach Building structure Other paved surface Storm drain Street/curb& gutter Surface water Unpaved surface Other (specify): Estimated spill volume (in gallons 1,000gal or more = Category 1): Method calculated: Est. volume of SSO recovered (gal): Were photos taken? No Yes how many? Estimated volume of spill reaching surface water, drainage channel, or not recovered from a storm drain (gal): C. SPILL OCCURRING TIME Estimated spill start date and time: Date and time spill reported to sewer crew: Estimated spill end date and time: Date and time sewer crew arrived: D. CAUSE OF SPILL Location of Blockage: Main Lateral Private Lateral Other SSO cause (check all that apply): Debris/Blockage Flow exceeded capacity Grease Operator error Roots Pipe problem/failure Pump station failure Rainfall exceeded design Vandalism Inflow/infiltration Animal carcass Electrical power failure Bypass Debris from laterals Construction Debris Other (specify): Weather conditions prior 72 hours: Sunny Weather Cloudy Weather Measurable Rain Rain for Several Days If SSO is caused by wet weather, choose size of storm: 1-yr 2-yr 5-yr 10-yr 50-yr 100-yr >100-yr Unknown Diameter (in inches) of pipe at point of blockage/spill cause (if applicable): Sewer pipe material at point of blockage/spill cause (if applicable): Description of terrain surrounding point of blockage/spill cause: Flat Mixed Steep E. SPILL RESPONSE Spill response activities (check all that apply): Cleaned up Contained all/portion of spill TV inspection Restored flow Returned all/portion of spill to sanitary sewer Other (specify): Spill response completed (date & time): Name of impacted waters (if applicable): Visual inspection result of impacted waters (if applicable): Any fish killed? Yes No Any ongoing investigation? Yes No Name of impacted beach (if applicable): Health warning/beach closure posting/details: Were health warnings posted? Yes No Were samples of impacted waters collected? Yes No If YES, select the analyses: DO Ammonia Bacti Other Recommended corrective actions: Add sewer to PM Program Adjust PM schedule Adjust PM method Rehab sewer Replace sewer Enforcement action against FOG source Other (specify): F. NOTIFICATION DETAILS CalEMA contacted date and time (if applicable): CalEMA Control Number (if applicable): GO TO SIDE B Spoke to:

4 Sanitary Sewer Overflow Response Packet Sanitary Sewer Overflow Report OP-2 Side B Immediate Regulatory Reporting Guide: If any of the following conditions exist, immediately contact one of the individuals on the list below and request that they make notifications as indicated in the Regulatory Notifications Packet: Estimated volume is greater than 1,000 gallons SSO was discharged to a drainage channel or surface waters SSO was discharged to a storm drain and not fully captured and returned PERSON BUSINESS HOURS AFTER HOURS Assistant Wastewater Superintendent Collections Manager RECOMMENDED FOLLOW-UP ACTIONS TO PREVENT FUTURE OCCURRENCES CURRENT PM FREQUENCY: DATE OF LAST PM: RECOMMENDED ACTIONS: TV RE-RUN CHANGE CLEANING SCHEDULE REPAIR LINE SEGMENT REPLACE LINE SEGMENT OTHER (describe): NOTES: Place completed form in Sewer Overflow Envelope and follow routing instructions.

5 Sanitary Sewer Backup Response Collection System Failure Analysis OP-3 Incident Report # SSO/Backup Information Event Date/Time Volume Spilled Cause Address Volume Recovered Prepared By Summary of Historical SSOs/Backups/Service Calls/Other Problems Date Cause Date Last Cleaned Crew Records Reviewed By Record Review Date Summary of CCTV Information CCTV Inspection Date CCTV Tape Reviewed By Tape Name/Number CCTV Review Date Observations Recommendations No Changes or Repairs Required Maintenance Equipment Maintenance Frequency Repair (Location and Type) Add to Capital Improvement Rehabilitation/Replacement List: Yes No Supervisor Review Date Superintendent Review Date

6 Sanitary Sewer Backup Response Packet Claims Submittal Checklist OP-4