**Example Form –**  **Sewer Overflow Event Report EPA Regulations**  **– 122.41(I**  **)(6) and (7) Example**  **Data Entry Form** [ **Note:** Users will also be able to batch this data into this form via a spreadsheet or CSV file. ]
1. POTW NPDES Permit Number < system generated> 2. Start Date of Reporting Period (YYYY
- MM
- DD ) (i.e., start of sewer overflows ) 3. End Date of Reporting Period (YYYY
- MM
- DD ) (i.e., end or projected end of sewer overflows ) 4. NPDES Data Group Number 9 < system generated> 5. For each individual sewer overflow p lease identify the associated permitted feature(s) (if any) **OR** the latitude and longitude. **Sewer Overflow Discharge Number**  **<system generated> Permitted Feature** 

**Number Associated with a Sewer Overflow**  **Sewer Overflow NOT**  **Associated with Permitted Feature**  **- Latitude**  **Sewer Overflow NOT Associ ated**  **with Permitted Feature –**  **Longitude** 1 2 3

.

.

. [ **Note:** This table will allow users to report on more than one sewer overflow with one Sewer Overflow Event Report. For example, large storms can produce multiple sewer overflows. POTWs can report these multiple overflows on one report if they occur over the same approximate date range. The Sewer Overflow Discharge Number will be system generated and will be used throug hout this report . Users do not need to report the latitude and longitude of the individual sewer overflow if it is associated with a permitted feature. ]Users can use this map to identify the latitude and longitude of sewer overflows NOT

associated with a permitted feature
. [Note: The user will be able to pan and zoom to identify the location of the sewer overflow. This will return a latitude and longitude with the corresponding metadata (e.g., Horizontal Reference Datum) for each Sewer Overflow Discharge Number, which will be system generated. ]

6. Please provide the following information for each Sewer Overflow Discharge Number
. **Sewer Overflow Discharge Number**  **<system generated> Type of Sewer** 

**Overflow (SSO, CSO,**  **or Bypass) Duration of** 

**Sewer Overflow**  **(hours) Sewer Overflow** 

**Discharge Volume (gallons)**  **[Note:** Please provide your best estimate. **] Type of Sewer**  **Overflow by Weather Receiving**  **Waterbody Name for Permitted**  **Feature *** **Dry Wet**  1 2 3

.

.

. * **Note:** The above field will be auto

- populated by an EPA webservice in order to help to standardize waterbody names.7. Please indicate the known or likely cause (s) of the sewer overflow. Please check all that apply.

**Sewer Collection System Problems Sewer**  **Overflow Discharge Number 1**  **2 3**  **...** Mechanical Failure Fats/Oil/Grease Pump Station Electrical Failure Pump Station Capacity Inadequate Sewer System Capacity Tree Roots Other (please specify): <insert text> <insert text> < insert text> <insert text> **Plant Operation Problems Sewer Overflow Discharge Number** **s 1**  **2 3**  **...** Blockage at POTW Operations Inadequate POTW Capacity Due to POTW Operating at Design Capacity Inadequate POTW Capacity Due to Stormwater Event Flooding of POTW Due to Hurricane or Large Stormwater Event Flooding of POTW Due to Snowmelt POTW Electrical Failure Sewer Overflow Necessary for Update of POTW Other (please specify) : <insert text> <insert text> <insert text> < insert text>8. Please indicate the corrective a ction ( s ) t aken or p lanned for this s ewer overflow. Please check all that apply.

**Short Term Corrective Actions Sewer Overflow Discharge Numbers**  **1 2**  **3 ...**  Fix electrical problem Street sweeping and cleaning Sewer flushing Solid waste reduction and recycling Area/foundation drain, roof leader disconnection Fix broken pipe Catch basin cleaning Screens and trash racks Infiltration and inflow control Fix mechanical problem Public education programs In
-sewer storage Industrial pretreatment Other (please specify): <insert text> <insert text> <insert text> <insert text> **Long Term Corrective Actions Sewer Overflow Discharge Numbers**  **1 2**  **3 ...**  Sewer separation Disinfection Upgrade WWTP capacity Swirl concentrators/vortex separators Sewer rehabilitation Primary sedimentation Outfall elimination Retention basins Storage tunnels and conduits Upgrade pump station capacity Other (please specify): <insert text> <insert text> <insert text> <insert text>

### Standard Signature Block and Certification

Statement for CWA Reporting (in compliance with CFR Parts 3, 122.22, and 127). 9. Please indicate the type of p otential i mpact of the reported sewer overflow event. Please check all that apply. **Human Health Impacts of Sewer Overflow Event**  **Sewer Overflow Discharge Numbers 1**  **2 3**  **...** Beach closures Odors Shellfish bed closures Drinking water contamination Fishing and shell

-fishing restrictions Other (please specify): <insert text> <insert text> < insert text> <insert text> **Environmental Impacts of Sewer Overflow Event Sewer Overflow Discharge Numbers**  **1 2**  **3 ...**  Aesthetic impairment Aquatic life impairment Fish kills Aquatic habitat impairment Eutrophication Algal blooms Other (please specify) : <insert text> <insert text> <insert text> <insert text>

SUBMIT REPORT