"Sso Reporting Form" - Oregon

Sso Reporting Form is a legal document that was released by the Oregon Department of Environmental Quality - a government authority operating within Oregon.

Form Details:

  • Released on December 21, 2016;
  • The latest edition currently provided by the Oregon Department of Environmental Quality;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Oregon Department of Environmental Quality.

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Download "Sso Reporting Form" - Oregon

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SSO
Oregon Department of Environmental Quality
SSO Reporting Form
This information must be submitted within 5 days of becoming aware of the overflow.
Please complete online and print for signature. Be sure to fill out all fields.
FACILITY/CONTACT INFORMATION
Name of Permittee:
Contact Name:
Email:
County:
Phone:
DEQ Permit # (see permit face page):
DEQ File #:
OERS Incident #:
Date Reported to OERS:
Date Reported To DEQ:
Today's Date:
Date SSO Started (if known):
Time Started (if known):
Date SSO Stopped (if known):
Time Stopped (if known):
SSO Location:
SSO Nearest Address:
City:
Zip Code:
SSO Latitude (if known):
Longitude (if known):
Estimate of Quantity Overflowed:
(Gallons)
Link to estimation method
Did the SSO discharge to surface water?
Name of waterbody:
PUBLIC NOTIFICATION
Notified downstream drinking water sources (List Below)?
Name of drinking water facility:
Signs Posted?
Media contacted?
Who?
List any other steps taken to notify the public or state/federal agencies:
CAUSES
Cause or suspected cause of the overflow:
If needed, attach additional sheets
Rainfall in the 24 hours prior to SSO (for storm-related overflows):
(inches)
Source of rainfall data:
If needed, attach additional sheets
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1
SSO
Oregon Department of Environmental Quality
SSO Reporting Form
This information must be submitted within 5 days of becoming aware of the overflow.
Please complete online and print for signature. Be sure to fill out all fields.
FACILITY/CONTACT INFORMATION
Name of Permittee:
Contact Name:
Email:
County:
Phone:
DEQ Permit # (see permit face page):
DEQ File #:
OERS Incident #:
Date Reported to OERS:
Date Reported To DEQ:
Today's Date:
Date SSO Started (if known):
Time Started (if known):
Date SSO Stopped (if known):
Time Stopped (if known):
SSO Location:
SSO Nearest Address:
City:
Zip Code:
SSO Latitude (if known):
Longitude (if known):
Estimate of Quantity Overflowed:
(Gallons)
Link to estimation method
Did the SSO discharge to surface water?
Name of waterbody:
PUBLIC NOTIFICATION
Notified downstream drinking water sources (List Below)?
Name of drinking water facility:
Signs Posted?
Media contacted?
Who?
List any other steps taken to notify the public or state/federal agencies:
CAUSES
Cause or suspected cause of the overflow:
If needed, attach additional sheets
Rainfall in the 24 hours prior to SSO (for storm-related overflows):
(inches)
Source of rainfall data:
If needed, attach additional sheets
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1-in-5 year 24 hour rainfall for the sewerage system area (if known):
(in/24hr)
EMERGENCY RESPONSE AND MITIGATION
List actions taken to stop and mitigate the impact of the SSO.
For overland flow:
Taped off affected area?
Cleaned up affected area?
For SSO to surface water:
Bacteria samples taken to confirm impact?
Follow up bacteria samples taken to confirm end of impact?
Describe monitoring and results:
For SSOs that impact buildings: Pumped out flooded buildings?
Disinfected?
Other measures taken (describe):
Steps taken or planned to reduce, eliminate, and prevent the reoccurrence of the overflow and schedule for
those steps:
COMMENTS
I CERTIFY UNDER PENALTY OF LAW THAT THIS DOCUMENT AND ALL ATTACHMENTS WERE PREPARED UNDER MY DIRECTION OR
SUPERVISION IN ACCORDANCE WITH A SYSTEM DESIGNED TO ASSURE THAT QUALIFIED PERSONNEL PROPERLY GATHER AND
EVALUATE THE INFORMATION SUBMITTED. BASED ON MY INQUIRY OF THE PERSON OR PERSONS WHO MANAGE THE SYSTEM, OR
THOSE PERSONS DIRECTLY RESPONSIBLE FOR GATHERING THE INFORMATION, THE INFORMATION SUBMITTED IS, TO THE BEST OF
MY KNOWLEDGE AND BELIEF, TRUE, ACCURATE, AND COMPLETE. I AM AWARE THAT THERE ARE SIGNIFICANT PENALTIES FOR
SUBMITTING FALSE INFORMATION, INCLUDING THE POSSIBILITY OF FINE AND IMPRISONMENT FOR KNOWING VIOLATIONS.
Authorized Signature
Date
____________________________________________________
______________________________________
Name (print)
Phone Number
* You may attach additional information to this report before sending to DEQ as needed to explain the circumstances of the
overflow. This information may include but is not limited to: maintenance records and bacteria monitoring results.
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Upon completion, print out this form and send to the appropriate DEQ Address:
Portland-Permit Coordinator
Salem-Permit Coordinator
Pendleton-Permit Coordinator
800 SE Emigrant, #330 Pendleton,
700 NE Multnomah St., Suite 600
4026 Fairview Industrial Dr. SE
Portland, OR 97232
OR 97801
Salem, OR 97302
FOR DEQ PERSONNEL ONLY
Pre-Enforcement Notice
Warning Letter
No enforcement action was warranted because:
The SSO was caused by unpreventable vandalism or similar force majeure; or
The SSO is allowed as an exception to the permit as maintenance; or
The cause of the current SSO was beyond reasonable control AND we do not expect the premittee to prevent
similar SSOs in the future; or
The SSO was 400 gallons or less, spilled to the ground and not reaching surface water; permittee properly
reported, cleaned up, and took appropriate public notice measures; and the SSO was not part of a chronic
problem.
COMMENTS
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