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c o L o R A D o Five day reporting form <br /> AT. Water <br /> Duality Control Division <br /> Department of%blic Health&Environment Incident / spill / sanitary sewer overflow release <br /> Use this form to report incidents impacting waters of the state <br /> The Water Quality Control Division distinguishes between reporting requirements for incidents that occur at entities <br /> operating under a Colorado Discharge Permit System (CDPS) permit and those resulting from non-permitted activities. <br /> Permitted activities - Reporting and management of non-compliance incidents and spills that occur as a result of <br /> permitted activities should be performed in accordance with the specific requirements in the notifications section of <br /> your permit. You may use this form to submit the information requested in the permit. <br /> Non-permitted activities - In the case of an activity where a permit does not address reporting of, or response to, a <br /> given spill please submit a written summary of the event, your response, and clean up efforts to the division within five <br /> working days of the date of the event. This form is provided for your convenience. If you have any questions please <br /> contact the division's field services staff person assigned to your spill case. <br /> Prior to the five working day deadline you may request an extension to submit the report if needed for sampling <br /> analysis or other reasons. To request an extension please send an email to the division's field services staff person <br /> assigned to your spill case or to the spill administrator. The field services contact list is available at: <br /> www.colorado.gov/cdphe/wq-inspection-services-contact-us. <br /> Please send the completed form or report with signature to the division's field services spill administrator: <br /> Michelle Thiebaud Telephone: 970-248-7150 <br /> 222 S. Sixth Street, 232 Fax: 970-248-7198 <br /> Grand Junction, CO 81501 Email: michelle.thiebaud@state.co.us <br /> 1. Incident background information <br /> r 2021-0165 Date of April 27, 20212 County Summit <br /> (division provided) event <br /> Incident/spill numbe <br /> Type of incident / spill / SSO check one <br /> ❑ Sanitary sewer overflow ❑ Potable water/reuse water/ ❑ Biosolids <br /> reclaimed water <br /> ❑ Wastewater treatment plant bypass or ❑ Petroleum product ❑ Oil or gas field production spill <br /> upset (authorized outfall point) <br /> ❑ Wastewater treatment plant spill or ❑ Chemical ® Other <br /> overflow other than outfall <br /> Estimated volume released 1,800 gallons <br /> Size and depth of area affected Not applicable <br /> Contact information <br /> Potentially responsible party contact name Diana Kelts, Environmental Manager <br /> Potentially responsible party company/agency name Climax Mine <br /> CDPHE Permit number and facility name (if applicable) Incident occurred up-gradient from Outfall 001A identified in the Climax <br /> Mine CDPS Permit No. C00000248 <br /> Email address dkelts@fmi.com Phone 719-486-7525 <br /> 2. Incident information: Please provide the following information. <br /> A. Describe incident including source, cause, and location (e.g. address, latitude/longitude). <br /> At 12:30pm on April 27, 2021 an operator maintaining the West Interceptor Ditch road noticed excess water flowing on the road <br /> and into the West Interceptor. At 1:45pm Climax confirmed that the water was coming from the Climax Property Discharge Water <br /> Treatment Plant (PDWTP) influent pipeline located adjacent to the West Interceptor. Site supervision was contacted and the <br /> pump feeding the line was shutdown. Operators at the leak location indicated that flow stopped from the leak at 3:30pm. After <br /> the pipeline was excavated the following day on April 28, 2021, it was determined that the 42" steel pipe had formed a crack at a <br /> welded joint causing the leak. The incident occurred at the Climax Mine located at Fremont Pass- Highway 91 Climax, CO 80429. <br /> The attached map shows the location of the leak. <br /> B. Material released, e.g. untreated wastewater, specific chemical or product, biosolids. Please attach the OSHA Material Safety <br /> Data Sheets for any and all chemicals or products ins ill or release. <br /> pH neutral water from the Mayflower Tailing Storage Facility <br />