| Spill Details |
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| *18 - Spill appearance point: |
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19 - Spill appearance point explanation:
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| *20 - Did the spill discharge to a drainage channel and/or surface water? |
und
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| *21 - Did the spill reach a separate (i.e.,not combined) storm drainpipe? |
und
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| *22 - If spill reached to a separate storm drainpipe, was all of the wastewater fully captured from the separate storm drain and returned to the sanitary sewer system? |
und
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| *23 - Private lateral spill? |
und
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| 24 - Name of responsible party (for private lateral spill only, if known): |
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*25 - Final spill destination:
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und
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26 - Explanation of final spill destination:
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und
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| *27 - Estimated spill volume: |
0 gallons
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28 - Estimated volume of spill recovered: |
0 gallons
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| *1.1 - Estimated volume of spill that reached surface water, drainage channel, or not recovered from a separate storm drain: |
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| 29 - Estimated current spill rate (if applicable): |
0 gallons per minute |
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| *30 - Estimated spill start date/time: |
01/01/1900
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| *31 - Date and time sanitary sewer system agency was notified of or discovered spill: |
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| *32 - Estimated Operator arrival date/time: |
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| *33 - Estimated spill end date/time: |
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| *34 - Spill cause: |
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35 - Spill cause explanation:
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| 36 - Where did failure occur? |
und
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37 - Explanation of Where failure occured:
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und
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| 38 - If spill caused by wet weather, choose size of storm: |
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| 39 - Diameter of sewer pipe at the point of blockage or spill cause (if applicable): |
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| 40 - Material of sewer pipe at the point of blockage or spill cause (if applicable): |
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| 41 - Estimated age of sewer pipe at the point of blockage or spill cause (if applicable): |
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| 42 - Description of terrain surrounding the point of blockage or spill cause (if applicable): |
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*43 - Spill response activities:
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44 - Explanation of spill response activities:
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| 45 - Visual inspection results from impacted receiving water: |
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| *1.3 - Health warnings posted? |
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| 46a - Name of impacted beach(es) (enter NA if not applicable): |
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| *46b - Name of impacted surface water(s) (enter NA if not applicable): |
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| Notification Details |
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47 - OES Control Number
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48 - OES Called Date/Time
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| 49 - Regional Water Quality Control Board notified date/time: |
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| 50 - Method Notification: |
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| 51 - Name of Staff Contacted: |
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| 52 - Phone Number of Staff Contacted: |
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| 53 - Other Agency Notified: |
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| 54 - Was any of this spill report information submitted via fax (or electronically) to the Regional
Water Quality Control Board? |
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55 - Date and time spill report information was submitted via
fax (or electronically) to the Regional Water quality Control Board:
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