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 please 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 Associated 

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 throughout 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 

Dry Wet Feature *

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 Numbers

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 action(s) taken or planned for this sewer 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 potential impact 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