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© 2004-2016 DKF Solutions Group All rights reserved. City of Redwood City: Overflow Emergency Response Plan B-4 Side 2 Sanitary Sewer Overflow/Backup Response Packet Sanitary Sewer Overflow Report D. CAUSE OF SSO Where did failure occur? (Check all that apply):  Air Relief or Blow-Off Valve  Force Main  Gravity Mainline  Siphon  Lower Lateral (public)  Manhole  Pump Station (specify): OControls OMechanical OPower  Lateral (private)  Service Lateral or Lower Lateral  Other: SSO cause (check all that apply):  Air Relief or Blow-Off Valve Failure  Construction Diversion Failure  CS Maintenance  Damage by others  Debris (specify): Ofrom Construction Ofrom Lateral OGeneral ORags  Flow Exceeded Capacity  FOG (Fats, oil, grease)  Inappropriate Discharge  Natural Disaster  Operator Error  Root Intrusion  Pipe Structural Problem/Failure  Pipe Structural Problem/Failure (Installation)  Rainfall Exceeded Design  Pump Station Failure (specify): OControls OMechanical OPower  Roots  Siphon Failure  Vandalism  Surcharged Pipe  Non - Dispersible Wipes  Other (specify): Diameter (in inches) of pipe at point of blockage/spill cause (if applicable): Sewer pipe material at point of blockage/spill cause (if applicable): Estimated age of sewer asset at the point of blockage or failure (if applicable): Description of terrain surrounding point of blockage/spill cause:  Flat  Mixed  Steep E. SSO RESPONSE SSO response activities (check all that apply):  Cleaned-Up  Mitigated Effects of Spill  Contained All or Portion of Spill  Restored Flow  Returned All Spill to Sanitary Sewer System  Returned Portion of Spill to Sanitary Sewer System  Property Owner Notified  Other Enforcement Agency Notified (specify)  Other (specify): SSO response completed (date & time): Visual inspection result of impacted waters (if applicable): Any fish killed?  Yes  No Any ongoing investigation?  Yes  No Were health warnings posted?  Yes  No If yes, provide health warning/beach closure posting/details: Was there a beach closure?  Yes  No If yes, name of closed beach(es): Were samples of impacted waters collected?  Yes  No If YES, select the analyses:  DO  Ammonia  Bacteria  pH  Temperature  Other: Recommended corrective actions: (check all that apply and provide detail)  Add sewer to preventive maintenance program  Adjust schedule/method of preventive maintenance  Enforcement action against FOG source  Inspect sewer using CCTV to determine cause  Plan rehabilitation or replacement of sewer  Repair facilities or replace defect  Remove roots  Spot repair  Other (specify): What major equipment was used in the response? List all agency personnel involved in the response including name, title and their role in the response: F. NOTES G. NOTIFICATION DETAILS: Enter details if applicable CalOES contacted on (Date and Time): Spoke to: CalOES Control Number: This form prepared by: NAME: TITLE: DATE: This form reviewed by: NAME: TITLE: DATE: Place completed form in Sanitary Sewer Overflow/Backup Response Envelope and follow routing instructions. 6.2.A. - Page 144