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ATTACHMENT B S50 Response Report Form Work Order# Date Operator Incident Comma nder Street Address Cross Street Vaccon 119 Pleasanton,Alameda County Vaccon 102 Regional Water Quality Control Board:Region 2-San Francisco Bay Fl usher 116A SSO Start Time TV Truck CoP Utilities Notified Time 550 Type Additional Personnel Operator Arrival Time _ ❑ Public ❑ ArcMap snowing Sewer and Storm Drain SSO Stop Time ❑ Private ❑ Digital Camera Required Did SSO reach Storm Drain? Y/N Did spill reach Receiving Waters? Y/N Weather Conditions: ❑ Dry, ❑ Wet Estimated Spill Volume(gal) Reporting Completed By Estimated Spill Volume Recovered(gal) Can sewer pipe be START SSO lQSSth RelieveSSO SSO Stop TV'd while Vaccon(s) TV sewer do Time are relieving SSO at main RELIEF 20 at Manhole GPM with Vaccon manhole? downstream of plug What is the SSO possible ❑Yes ❑ No possible flow estimate? GPM ,�; No Great P El Photos ReauireQ rthar! Relieve SSO plug with ? 20 GPM penetrating nozzle,but Plug Cleared TV sewer main Fully clean sewer ❑Video If Possible DO NOT clean pipe Time L downstream of _ main andTV(if plug(if not practical) ` already done) Start Has ANY volume of Estimated Impact Within two(2)hours Containment Yes . SSO reached Receiving ' YeS of SSO Start Time you Waters? ___ _GAL MUST notify Has ANY ❑ Yes ❑ No ❑ Photos Required Volume of SSO ❑ Samples Required ❑ (800)852-7550 reached a Office of Emergency Storm Drain 3 NO Services and obtain Inlet? Control it Use all available resources Estimated Volume ❑Yes to prevent Sewage from Recovered from DI ❑ (510) 567-6714 reaching DI(e.g.dams, . Supervisor Enviromental ❑ No — NO absorbents,plugs,etc) GAL Health Specialist, ❑ Photos Required Cynthia Bartus ❑ Photos Required ' Category 3 SSO Category 2 SSO START REPORTING Category 1550 SSO volume is than 5S0 volume isgreaterthan 1000 gallons and has not 1000 gallons and has not Did any 550 volu me reached receiving waters reached receiving waters reach receiving waters? ❑ Initial Online Report within ? ❑ Initial Online Business Days ❑ Final Online _ Report within 3 ❑ Yes D Report within Business Days ❑ Final Online 30 Calendar Days ❑ Final Online 1:3 N Report within 15 Report within Calendar Days 15 Calendar 1 Reporting Website:cwqs.waterboards.ca.gov.ciwqs 49IPage