NC0037311_Regional Office Historical File Pre 2016

North Carolina Department of Environmental Quality
Pat McCrory Donald R. van der Vaart
Governor Secretary
November 16, 2015
Allegiance Healthcare Investors, LLC
Attn: William R. Hammonds, Consultant.Management
P.O. -Box 485
Kernersville, NC 27284-0485
SUBJECT: Compliance Evaluation Inspection
Creekside Manor Assisted Living Wastewater Treatment Plant
NPDES Permit: NCO037311
Forsyth County
Dear Mr. Hammonds:
Ron Boone of the Winston Salem Regional Office (WSRO) of the North Carolina Division of Water
Resources (DWR or the Division) conducted a compliance evaluation inspection of the Creekside Manor Assisted
Living's Wastewater Treatment Plant on November 10, 2015. The assistance and cogperation of Cliff Gain, Operator
in Responsible Charge (ORC), was greatly appreciated. An inspection report is attached for your records and the
inspection findings are summarized below. .
The Creekside Manor Assisted Living's Wastewater Treatment Plant is located at 6206 Reidsville Road in
Kernersville, Forsyth County, North Carolina, at approximate coordinates 36.213262 ° west, 80.0643980 north.
Creekside Manor Assisted Living is authorized to operate this 0.010 million -gallon -per -day (MGD) wastewater
treatment plant, which consists of a bar screen, an aeration basin with diffused air, a secondary clarifier, tablet
chlorination, a chlorine contact basin, tablet dechlorination, and a sludge holding tank, and discharge treated effluent
from outfall 001 of said treatment works, which is located approximately 317 feet northeast of the treatment works at
approximate coordinates 36.213770 ° West, 80.063533° North, to an unnamed tributary of Belews Creek, which is
currently classified as Class C waters and is located in the Roanoke River Basin.
SITE REVIEW
Mr. Boone reviewed the entire plant with Mr. Cain. He seems be to doing a good job operating and
maintaining the plant. All components appeared to be in good condition and were operating as they should be. No
discrepancies or violations were noted.
DOCUMENTATION REVIEW
Mr. Cain had all required documentation for the inspection and everything was complete and current. Mr.
Boone found no discrepancies or violations. Mr. Cain has also done a good job of documenting his operation and
maintenance of the plant.
Please keep up the good work in ensuring the Creekside Manor Assisted Living's Wastewater Treatment
Plant is properly operated and maintained and meeting all the terms and conditions of the permit. Please remember
that violations of the permit are subject to enforcement actions not to exceed $25,000 per day, per violation.
North Carolina Division of Water Resources, Winston-Salem Regional Office
Location: 450 West Hanes Mill Road, Suite #300, Winston-Salem, North Carolina 27105
Phone: [phone] FAX: [phone] Customer Service;1-877-623-6748
Internet: www.ncwaterquality.org
An Equal Opportunity 1 Affirmative Action Employer

If you have any questions regarding the inspection or this letter, please do not hesitate to contact Mr. Boone
or me at 336-776-9800. Thank you for your cooperation in this matter.
Sincerely,
Sherri V. Knight
Asst. Regional Supervisor
Water Quality Regional Operations
Division of Water Resources
Attachments:
1. BIMS Inspection Report
CC: Central Files
NPDES Unit
�llltJ/SWP Files
R& Labs
Attn: Cliff Cain, Operator in Responsible Charge
106 Short Street
P.O. Box 473
Kernersville, NC 27284

United States Environmental Protection Agency
Form Approved.
EPA Washington, D.C.20460
OMB No. 2040-0057
Water Compliance Inspection Report
Approval expires B-31-98
Section A: National Data System Coding (i.e., PCS)
Transaction Code NPDES yr/mo/day Inspection Type Inspector Fac Type
1 JN 1 2 15 1 3 I NCO037311 111 12 15/11/10 117 18 LCJ 19 L s j 20I
__
211111111111111111111111111 IIliii IIIIIIiiiiI t66
Inspection
Work Days Facility Self -Monitoring Evaluation Rating 131 CIA --------------Reserved ----- ------
67
70 L_j71 I I 72 �, 73 I I 174 75
LJ I I
80
Section B: Facility Data
Name and Location of Facility Inspected (For Industrial Users discharging to POTW, also include
Entry Time/Date
Permit Effective Date
POTW name and NPDES permit Number)
10:00AM 15/11/10
12/03/01
Creekside Manor Assisted Living
Exit Time/Date
permit Expiration Date
6206 Reidsville Rd
11:00AM 15/11/10
17/02/28
Kernersville NC 27284
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
Other Facility Data
Clifford Curtis Cain/ORC/336-996-2841/
Name, Address of Responsible Official/Title/Phone and Fax Number
Contacted
James Cheshire,6206 Reidsville Rd Kernersville NC 27284//336-996-2841/
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit Flow Measurement Operations & Maintenance Records/Reports
Self -Monitoring Program Sludge Handling Disposal Facility Site Review Effluent/Receiving Waters
Laboratory
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
(See, attachment summary)
Name(s) and Signature(s) of Inspector(s) Agency/Office/Phone and Fax Numbers Date
Ron Boone WSRO WQ//336-776-9690/
Z.f
Signature oof` Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
d /
is
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page#

NPDES yr/mo/day Inspection Type 1
31 NCO037311 I11 12 15/11/10 17 18 ICI
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
Please refer to the attached inspection summary letter.
Page#

I
Permit: NC0037311 owner - Facility: Creekside Manor Assisted Living
Inspection Date: 11/10/2015 Inspection Type: Compliance Evaluation
Permit
Yes No NA NE
(If the present permit expires in 6 months or less). Has the permittee submitted a new
❑
❑
0
❑
application?
Is the facility as described in the permit?
❑
❑
❑
# Are there any special, conditions for the permit?
❑
❑
❑
Is access to the plant site restricted to the general public?
❑
❑
❑
Is the inspector granted access to all areas for inspection?
0
❑
❑
❑
Comment: None
Record Keepinq
Yes No NA NE
Are records kept and maintained as required by the permit?
N
❑
❑
❑
Is all required information readily available, complete and current?
0
❑
❑
❑
Are all records maintained for 3 years (lab. reg. required 5 years)?
N
❑
❑
❑
Are analytical results consistent with data reported on DMRs?
0
❑
❑
❑
Is the chain -of -custody complete?
S
❑
❑
❑
Dates, times and location of sampling
Name of individual performing the sampling
Results of analysis and calibration
Dates of analysis
Name of person performing analyses
Transported COCs
Are DMRs complete: do they include all permit parameters?
S
❑
❑
❑
Has the facility submitted its annual compliance report to users and DWQ?
❑
❑
0
❑
(If the facility is = or > 5 MGD permitted flow) Do they operate 24/7 with a certified operator
❑
0
❑
❑
on each shift?
Is the ORC visitation log available and current?
E
❑
❑
❑
Is the ORC certified at grade equal to or higher than the facility classification?
E
❑
❑
❑
Is the backup operator certified at one grade less or greater than the facility classification?
N
❑
❑
❑
Is a copy of the current NPDES permit available on site?
❑
❑
❑
Facility has copy of previous year's Annual Report on file for review?
❑
❑
E
❑
Comment: None
Laboratory Yes No NA NE
Are field parameters performed by certified personnel or laboratory? 0 ❑ ❑ ❑
Are all other parameters(excluding field parameters) performed by a certified lab?. S ❑ ❑ ❑
Page# 3

1
Permit: NCO037311 Owner - Facility: Creekside Manor Assisted Living
Inspection Date: 11/10/2015 Inspection, Type: Compliance Evaluation
Laboratory
Yes No NA NE
# Is the facility using a contract lab?
0
❑
❑
❑
# Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees
❑
❑
❑
Celsius)?
Incubator (Fecal Coliform) set to 44.5 degrees Celsius+/- 0.2 degrees?
❑
❑
❑
Incubator (BOD) set to 20.0 degrees Celsius +/-1.0 degrees?
❑
❑
❑
Comment: None
Effluent Sampling
Yes No NA NE
Is composite sampling flow proportional?
❑
❑
0
❑
Is sample collected.below all treatment units?
0
❑
❑
❑
Is proper volume collected?
E
❑
❑
❑
Is the tubing clean?
❑
❑
0
❑
# Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees
❑
❑
❑
Celsius)?
Is the facility sampling performed as required by the permit (frequency, sampling type
N
❑
❑
❑
representative)?
Comment: None
Upstream / Downstream Sampling Yes No NA NE
Is the facility sampling performed as required by the permit (frequency, sampling type, and S ❑ ❑ ❑
sampling location)?
Comment: None
Bar Screens
Yes No NA NE
Type of bar screen
a.Manual
b.Mechanical
❑
Are the bars adequately screening debris?
❑
❑
❑
Is the screen free of excessive debris?
S
❑
❑
❑
Is disposal of screening in compliance?
0
❑
❑
❑
Is the unit in good condition?
N
❑
❑
❑
Comment: None
Aeration Basins Yes No NA NE
Page# 4

Permit: NCO037311
Owner - Facility: Creekside Manor Assisted Living
Inspection Date: 11/10/2015
Inspection Type: Compliance Evaluation
Aeration Basins
Yes No NA NE
Mode of operation
Ext. Air
Type of aeration system
Diffused
Is the basin free of dead spots?
0 ❑
❑
❑
Are surface aerators and mixers operational?
❑ ❑
E
❑
Are the diffusers operational?
N ❑
❑
❑
Is the foam the proper color for the treatment process?
0 ❑
❑
❑
Does the foam cover less than 25% of the basin's surface?
0 ❑
❑
❑
Is the DO level acceptable?
❑ ❑
❑
Is the DO level acceptable?(1.0 to 3.0 mg/1)
❑ ❑
❑
Comment: None
Secondary Clarifier
Yes No NA NE
Is the clarifier free of black and odorous wastewater?
S
❑
❑
❑
Is the site free of excessive buildup of solids in center well of circular clarifier?
❑
❑
0
❑
Are weirs level?
N
❑
❑
❑
Is the site free of weir blockage?
0
❑
❑
❑
Is the site free of evidence of short-circuiting?
❑
❑
❑
Is scum removal adequate?
N
❑
❑
❑
Is the site free of excessive floating sludge?
0
❑
❑
❑
Is the drive unit operational?
❑
❑
0
❑
Is the return rate acceptable (low turbulence)?
0
❑
❑
❑
Is the overflow clear of excessive solids/pin floc?
N
❑
❑
❑
Is the sludge blanket level acceptable? (Approximately % of the sidewall depth)
❑
❑
❑
Comment: None
Pumps-RAS-WAS
Yes No NA NE
Are pumps in place?
0
❑
❑
❑
Are pumps operational?
0
❑
❑
❑
Are there adequate spare parts and supplies on site?
0 .
❑
❑
❑
Comment: None
Disinfection -Tablet Yes No NA NE
Are tablet chlorinators operational? 0 ❑ ❑ ❑
Page# 5

Permit: NC0037311
Inspection Date: 11/10/2015
Owner -Facility: Creekside Manor Assisted Living
Inspection Type: Compliance Evaluation
Disinfection -Tablet
Yes No NA NE
Are the tablets the proper size and type?
N
❑
❑
❑
Number of tubes in use?
3 '
Is the level of chlorine residual acceptable?
❑
❑
❑
Is the contact chamber free of growth, or sludge buildup?
❑
❑
❑
Is there chlorine residual prior to de -chlorination?
❑
❑
❑
Comment: None
De -chlorination
Yes No NA NE
Type of system ?
Tablet
Is the feed ratio proportional to chlorine amount (1 to 1)?
0
❑
❑
❑
Is storage appropriate for cylinders?
E
❑
❑
❑
# Is de -chlorination substance stored away from chlorine containers?
E
❑
❑
❑
Are the tablets the proper size and type?
0
❑
❑
❑
Comment: None
Are tablet de -chlorinators operational? E ❑ ❑ ❑
Number of tubes in use? 3
Comment: None
Flow Measurement - Effluent
Yes No NA NE
# Is flow meter used for reporting?
E
❑
❑
❑
Is flow meter calibrated annually?
0
❑
❑
❑
Is the flow meter operational?
❑
❑
❑
(If units are separated) Does the chart recorder match the flow meter?
0
❑
❑
❑
Comment: None
Effluent Pipe
Yes No NA NE
Is right of way to the outfall properly maintained?
0
❑
❑
❑
Are the receiving water free of foam other than trace amounts and other debris?
N
❑
❑
❑
If effluent (diffuser pipes are required) are they operating properly?
❑
❑
N
❑
Comment: No effluent diffusers
Aerobic Digester Yes No NA NE
Is the capacity adequate? E ❑ ❑ ❑
Page# 6

i
Permit: NCO037311
Inspection Date: 11/10/2015
Owner - Facility: Creekside Manor Assisted Living
Inspection Type: Compliance Evaluation
Aerobic Digester
Yes No NA NE
Is the mixing adequate?
0
❑
❑
❑
Is the site free of excessive foaming in the tank?
❑
❑
❑
# Is the odor acceptable?
0
❑
❑
❑
# Is tankage available for properly waste sludge?
0
❑
❑
❑
Comment: None
Operations & Maintenance Yes No NA NE
Is the plant generally clean with acceptable housekeeping? 0 ❑ ❑ ❑
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable 0 ❑ ❑ ❑
Solids, pH, DO, Sludge Judge, and other that are applicable?
Comment: None
Page# 7

37
A&4#A
NC®ENR
North Carolina Department of Environment and Natural Resources
Pat McCrory Donald R. van der Vaart
Governor Secretary
July 16, 2015
Allegiance Healthcare Investors, LLC
Attn: William R. Hammonds, Consultant Management
P.O. Box 485
Kernersville, NC 27285-0485
Subject: NOTICE OF VIOLATION
NOV2015-LV-0462
Permit No. NCO037311
Creekside Manor Assisted Living
Forsyth County
Dear Mr. Hammonds:
A review of Creekside Manor Assisted Living's monitoring report for April 2015 showed the following
violations:
Parameter
Date
Limit Value
lie orted Value
Limit Type
Coliform, Fecal MF, M-FC
04/14/2015
400
4,000
Daily
Broth,44.5C
Maximum
Exceeded
Remedial actions, if not already implemented, should be taken to correct the above noncompliance problem.
Please be aware that violations of your NPDES permit could result in enforcement action by the Division of
Water Resources for this and any additional violations of State law.
If you should have any questions, please do not hesitate to contact Ron Boone at [phone].
cc: DWR — Central Files
Sincerely,
W. Corey Basinger
Regional Supervisor
Water Quality Regional Operations
Division of Water Resources
450 West Hanes Mill Road, Suite #300, Winston-Salem, NC 27105
Phone: [phone] Internet: www.ncdenr.gov
An Equal Opportunity 1 Affirmative Action Employer — Made in part by recycled paper

AMR Inc vWw Record
Facility: �d�'�c5i r� % /�na�'
Permit No.: 3 ? 3>/ _ Pipe No,:
Monthly Average Violations
. Dy / Month/Year:
Parameter
Permit Limit DMR Value
% Over Limit
Action
Weekly/Daily Violations
Date Parameter
Permit Limit Limit Type DMR Value
% Over Limit
Action
1
Monitoring Frequency Violations
Date Parameter
Permit Frequency Values Reported
# of Violations
Action
IOtherViolations/Staff Remarks:
�b u , aD t5 - LU- Dql.0y
Supervisor Remarks:
!
Completed by:c Date:
Assistant Regional
Supervisor Sign Off: Date:
Regional Supervisor Sign —
Off. Date:

RECEIVED
EFFLUENT N.C.Dept. of ENR
Apr' `�V JUN 16 201;
I4PDES PERMIT NO. NC 0037311 DISCHARGE NO. 001 MONTH -Mereh- YEAR 201
FACILITY NAME Creekside Manor CLASS 11 COUNTY Forsyth Winston-Salem
CERTIFIED LABORATORIES R & A Laboratories, Inc. CERTIFICATION NO. Regions ee
(List additional laboratories on the backside/page 2 of this form)
OPERATOR IN RESPONSIBLE CHARGE (ORC) Clifford Cain GRADE III CERTIFICATION NO. 11237
PERSON(S) COLLECTING SAMPLES Operators ORC PHONE [phone]
CHECK BOX IF ORC HAS CHANGED 0 NO FLOW / DISCHARGE FROM SITE
Mail ORIGINAL and ONE COPY to: C �7
ATTN: CENTRAL FILES X d4nt� C
DIVISION OF WATER QUALIOA (SIGNATURE 0 RATOR IN RESPONSIBLE CHARGE)
1617 MAIL SERVICE CENTER l BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS RALEIGH, NC 27699-1617 pUN - p)/ ' � ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. J U ! ,I � 0 5 2 015
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Facility Status: (Please check one of the following)
All monitoring data and sampling frequencies meet permit requirements
(including weekly averages, if applicable) Compliant
All monitoring data and sampling frequencies do NOT meet permit requirements EZ
Noncompliant
The permittee shall report to the Director or the appropriate Regional Office any noncompliance that potentially threatens public
health or the environment. Any information shall be provided orally within 24 hours from the time the permitte became aware of the
circumstances. A written submission shall also be provided within 5 days of the time the permittee becomes aware of the
circumstances.
If the facility is noncompliant, please attach a list of corrective actions being taken and a time -table for improvements to be
made as required by Part II.E.6 of the NPDES permit.
"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 a 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 fines and imprisonment for knowing violations."
James M. Cheshire (Authorized Aeent
ittee P as rint typ )
Md I)V ffAff
ignatur f Permit *** Date
(Requ ed unless submitted electronically)
6206 Reidsville Road, Kernersville NC 336-722-6054 02/28/17
Permittee Address Phone Number Permit Exp. Date
Certified Laboratory (2)
Certified Laboratory (3)
Certified Laboratory (4)
Certified Laboratory (5)
ADDITIONAL CERTIFIED LABORATORIES
PARAMETER CODES
Certification No.
Certification No.
Certification No.
Certification No.
Parameter Code assistance may be obtained by calling the NPDES Unit at at [phone], or by visiting the Surface Water Protection Section's
web site at h2o.enr.state.nc.us/was and linking to the Unit's information pages.
Use only units of measurement designated in the reporting facility's NPDES permit for reporting data.
* No Flow / Discharge From Site: Check this box if no discharge occurrs and, as a result, there are no data to be entered for all of the
parameters on the DMR for the entire monitoring period.
** ORC On Site?: ORC must visit facility and document visitation of facility as required per 15ANCAC8G.0204.
*** Signature of Permittee: If signed by other than the permitte, then the delegation of the signatory authority must be on file with the state per
15ANCAC2B.0506 (b) (2) (D).

NPDES NO: NC 0037311 DISCHARGE NO: 001 MONTH: April YEAR: 2015
FACILITY NAME: Creekside Manor COUNTY: Forsyth
I
STREAM: UT to Belews Creek STREAM: UT to Belews Creek
LOCATION: 100' ft. Above Discharge
A.--
upsirream
Enter Parameter Code above
Name and Units Below
LOCATION: 100' ft. Below Discharge
Downstream
Enter Parameter Code above
Name and Units Below
Copy DEM Form MR-3 (11/84)

RESEARCh & ANA[yTICA1
I-AbORATWES, INC.
Analytical/Process Consultations
Re: Creekside Manor — April 14, 2015 — Fecal
Increased Chlorine Feed rate & Pump contact tank. No non.:compliance since that date.
- Clifford Cain, ORC
P.O. Box 473 • 106 Short Street • Kernersville, North Carolina 27284 • 336-996-2841 • Fax [phone]
www.randalabs.com

HALMMONDS M ANAGEMENT� LEC
FACSIMILE TRANSMITTAL SHEET
TO: PROM:
Ronald Boone William Ham oands
COMPANY; DATE:`
Water Quality Regional Operationss 3/4/2015
FAX NUMBER TOTAL NO, OF P.A.GPS INCLUDING COVER
336-776-9797 3
PHONE NUWF,.R: SENDER'S PAX NUmt8k:
336-595-5999
RE; SENDER'S PHONE: NIIiL1TiL•R:
Creehsi.de Manor Violatifons 336-595-6004
Pj URGENT Ef FOP, REVIEW ❑ PL EASPI COMMENT ci PLE A.&E REPLY d PLEASE RECYCLE
Sincere Thanlm
William Hamnnonds
**This fax contains confidential infonnation. If you xeacb this fax in error, please notify the sender
for instructions.
PO 'BOX 485 KERN ERSVILLE, NC 27M

02/27/201.5 15.12 336-9960326 R & A LABORATORIES P416E b2103
ESvARc� ANAtYT* At
. bORATJxES� ING
�nQlyCicell��Gess ConSulteGians
27 February 2015
mr, Corey goluger
Regional qgupervisor
Water quw4jty Regional Operatians
DMsion of Water Ttesources
Walston -Salem Regime OITIQQ
450 WeRt Manes Mill Mad, Suite 300
Winston.8810m, NC 27105
Subject; p es�onse to NOV-2015-LV-0064
permit No. NCO0373I
Crcekside Manor Assisted Living
Forsyth Coutaty
TDesr Mr. Basinger:
Iu response to your NOV dated FebmrY 9, 2015 (i,e. geceivd 18 k'eb 2015) for Cy, ekside Manor
Assisteit res o or Creekslde �IWTP the contract NVWTP operatt�rs bive provided the f0llowin�g Te-Taloses:
1) The Croekside W'WTP bad been in co S was sistenreed d in November O14 inlean1unctio;a with
through Ootr�be' 2014 until efilucut TS
a r)ENR WWTp inspection an 20 Nov 2015.
th
l at the
2) On 31 Dooember 2014 it was reported 1 confirmed 1 lly qt ped and. waxd durings000ber 2014.
assisted living interior quarter floors were the sorlttel, unaware of past problems caused
Li addition, it wvas reported that new MdUtanance P have inadverteln'dY
by excessive discharge of toxic cleaning aherAicals to WWTP, may
relessed chemicals to WWTF that either p>artiallY apt completely caused the upset Or ROtivAtd
sludge iniubxtion to the WW'I'1'.
3 Er Z014 with �. Ron Baor(i e. fastlded
With "U-tual
The 1)ENR inspection iz► NOVerx1bsettIftsludge; 100 r0l
ag=rnont. to ineroase sludge wastitrg becaus hiF sum t5 d a.e of sludge." 7A(" WW'TP
5 min, turbid supe=tc, NH.}-N <1.0 ><r�,gli, et ) ggd
upb#! increasing the 5ludgewastingprogram did not improvo but in fact bec=c irtcreasiAglY
worse, After three (3) a,,mpts to reseed the seration bas%n with digest©x sludge omdlol" Other
VJW'1`P facility
activated sludge ovor a period of two (2) months it appears the WW'T'P is
beginning to sigoi15cantly improve but is not yet in i><.i.11 eomplianee (i.e. TSS, Nils- .
P D. Box 473. 1 OE Shari Streat • KernerWlleNp� dI�g�nlne 294 A S38-996-2841 0 F�1x 88� SN'0388
�

62l27'Y2e15 15:12 336-9960326 R & A LABORATORIES PAGE 03103
ht to be Old sludge may have been dead or ixthibited sltt(lge
'ties
4) 1t appears that what was thongsettle, As a On 1�
alf
microorsanisMs that MI) act to ei%ctively flo ou a vated kludge under as micros opo Oil 19
be difficult to interpret �axami you observed t
Feb 2015 we did exaxtauao the activated sludge a with a less dominant nnumb= of
zy
hadtby population of dordnat�t stallctd ciliated protozoan;udworms" were aloo observed
-fteo Swimming ciliated protozoan," A fOw (i.e, �) l � TS8 and
Besting a moderate to older sludge but at a Mix-B uOr concentration of 1130 mgll
logo mg/1 VSS.
wvo etl that it should not have taken this lbag to tutu this WWTF around i� the
S) In summary, "old sludge," It is im-PPorten, to note that
problem was QQrre 'interpreted as being i to Monitor
rmaaagerial / maintenance prOceduzcs have been initiated by carnp +xy ow A dint we are
qMd control the release of potentiall�r axxk�NV TprY t the i coMjngto t1le waste WWTF ad and expwctto see
basically restarting or reacclunating the VJ
cousi&,ut NPDES Gpmpliauce within tilt next 30 days-
Celcside manor Assisted Living sincereiy regrets alb�la'y° pact that may have been
a �, Ev�'Y eif'ort has been made in tizx�p an� se�eng s.
O to
l�iefly caused i tto xeceving updated on our prod
resolve this problem expeditiously �cn,d will kip7�NR p
positiv6 resolution.
Best Regards,
James M. Cheshire
Presidont/CEO
Rosearch & Analytical Laboratnries, Inc.
imcris
cc; Willi= *40mbaonds
Clifford Cain., ARC

ODE --
North Carolina Department;of Environment and Natural Resources .
Pat McCrory Donald R.:van. der Vaart
Governor Secretary
February 9, 2015 -
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
70.13-1710=0002-1865.5320
Allegiance. Healthcare Investors, LLC
Attn: William R. Hammonds, Consultant Management
P.O. Box 485
Kernersville, NC27285-.0485
Subject: Notice of Violation and Recommendation for Enforcement
NOV-2015-LV-0064
Permit No. NCO037311
Creekside Manor Assisted Living
Forsyth County
Dear Mr. Hammonds:
A review of Creekside Manor Assisted Living's monitoring report for November, 2014 showed the
following violations:
Parameter
Date
Limit Value
Reported Value
Limit Type
Total Suspended Solids
11/30/2014
30
44.5
Monthly Average
Total Suspended Solids
11/4/2014
45
47.1
Daily Max
Total Suspended Solids
11/11/2014
45
48
Daily Max
Total Suspended Solids
11-119/2014
45 .
46
Daily Max
A Notice of Violation/Notice of Recommendation for Enforcement (NOV/NRE) is being -issued for
the, noted violation(s) of North Carolina General Statute (G.S.) 143-215.1 and NPDES Permit No.
NCO037311. Pursuant to G.S. 143-215.6A, a civil penalty of not more than twenty-five thousand dollars
($25,000.00) may be assessed against any person who violates or fails to actin accordance with the terms,
conditions, or requirements of any permit issued pursuant to G.S. 143-215.1. If you wish to provide
North Carolina Division of Water Resources, Winston-Salem Regional Office
Location: 450 West Hanes Mill Road, Suite #300, Winston-Salem, North Carolina 27105
Phone: [phone] FAX: [phone] Customer Service;1-877-623-6748
Internet www.ncwaterquality.org
An Equal Opportunity 1 Affirmative Action Employer

additional information regarding the noted violation(s), request technical assistance, or discuss overall
compliance, please respond in writing within ten (10) days after receipt of this Notice. A review of
your response will be considered along with any information provided on the Creekside Manor Assisted
Living's, November, 2014 Discharge Monitoring Report. You will then be notified of any civil penalties that
may be assessed regarding the violation(s). If no response is received in this Office within the 10-day
period, a civil penalty assessment may be prepared.
Remedial actions, if not already implemented, should be taken to correct any problems. The
Division of Water Resources may pursue enforcement actions for this and any additional violation(s). If the
violation(s) are of a continuing nature, not . related to operation and/or maintenance problems, or you
anticipate remedial construction activities, then you may wish to consider applying for a Special Order by
Consent.
If you have questions concerning this matter, please do not hesitate to contact Ron Boone or me at
[phone].
Sincerely,
W. Corey Basinger
Regional Supervisor
Water Quality Regional Operations
Division of Water Resources
cc: Point Source Branch
SWP — Central Files
W&SO,File`s

Facility: l
,b�� / � / ° Aitei'
Permit No.: 37 3 / /
Pipe No.:
Month/Year:
Monthly Average Violations
Parameter
Permit Limit
DMr�R/Value
%/pOve�rr Limit
D
7'7 r 5
�^Action
�f'O i T Z
Weekly/Daily
Violations
Date
Parameter
Permit Limit Limit Type
DMR Value
% Over Limit Action
r Monitoring Frequency Violations
Date
Parameter
Permit Frequency
Values Reported
# of Violations Action
Other Violations/Staff Remarks:
off - GIs- LV- OD6�
Supervisor Remarks:
Completed by:
Assistant Regional
Supervisor Sign Off:
Date: 2 �z I S'
—�
Date:
Regional Supervisor Sign �2
Off: Date: ¢ r�7 2c�g'—

Creekside Manor of Forsyth, LLC
6206 Reidsville Road
Kernersville, North Carolina 27284
Phone:[phone]
Fax: [phone]
April 4, 2014
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Delegation of Signature Authority
Creekside Manor WWTP
NPDES Number NCO037311
To Whom It May Concern:
By notice of this letter, I hereby delegate signatory authority to each of the following individuals
for all permit applications, discharge monitoring reports, and other information relating to the
operations at Creekside Manor WWTP required by all applicable federal, state, and local
environmental agencies specifically with the requirements for signatory authority as specified in
15A NCAC 213.0506.
James M. Cheshire
President/CEO
Research & Analytical Laboratories, Inc.
If you have any questions regarding this letter, please feel free to contact James Cheshire at 336-
996-2841.
Sincerely,
William R. Hammonds
Consultant Management
Allegiance Healthcare Investors LLC
cc: Winston-Salem Regional Office, Water Quality Permitting Section

r
NCD►ENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
Water Quality Regional Operations
Pat McCrory John E. Skvarla, III
Governor Secretary
November 24, 2014
Allegiance Healthcare Investors, LLC
Attn: William R. Hammonds, Consultant Management
P.O. Box 485
Kemersville, NC 27284-0485
SUBJECT: Compliance Evaluation Inspection
Creekside Manor Assisted Living Wastewater Treatment Plant
-NPDES Permit: NCO087311
Forsyth County
Dear Mr. Hammonds:
Ron Boone of the Winston Salem Regional Office (WSRO) of the North Carolina Division of Water
Resources (DWR or the Division) conducted a compliance evaluation inspection of the Creekside Manor Assisted
Living's Wastewater Treatment Plant on November 20, 2014. The assistance and cooperation of Cliff Cain, Operator
in Responsible Charge (ORC), was greatly appreciated. An inspection report is attached for your records and the
inspection findings are summarized below.
The Creekside Manor Assisted Living's Wastewater Treatment Plant is located at 6206 Reidsville Road in
Kemersville, Forsyth County, North Carolina, at approximate coordinates 36.213262 ° West, 80.064398° North.
Creekside Manor Assisted Living is authorized to operate this 0.610 million -gallon -per -day (MGD) wastewater
treatment plant, which consists of a bar screen, an aeration basin with diffused air, a secondary clarifier, tablet
chlorination, a chlorine contact basin, tablet dechlorination, and a.sludge holding tank, and discharge treated effluent
from outfall 001 of said treatment works, which is located approximately 317 feet northeast of the treatment works at
approximate coordinates 36.213770 *,West, 80.0635330 North, to an unnamed tributary of Belews Creek, which is
currently classified as Class C waters and is located in the Roanoke River Basin.
SITE REVIEW
Mr. Boone reviewed the entire plant with Mr. Cain. The only thing noted was a layer of sludge on top of
the clarifier and pin floc escaping over the weir. Mr. Cain stated he thought the sludge was too old and would
immediately start wasting more to try to establish a younger sludge in the system. There were no other discrepancies
or violations noted. The plant appears to be operated and maintained well.
DOCUMENTATION REVIEW
North Carolina Division of Water Resources, Winston-Salem Regional Office
Location: 585 Waughtown St. Winston-Salem, North Carolina 27107
Phone: [phone] FAX [phone] Customer Service;1-877-623-6748
Internet: www.ncwaterquality.org
An Equal Opportunity 1 Affirmative Action Employer

Mr. Cain had all required documentation for the inspection and everything was complete and current. Mr.
Boone found no discrepancies or violations. Mr. Cain has done an excellent job of documenting his operation and
maintenance of the plant.
Please keep up the good work in ensuring the Creekside Manor Assisted Living's Wastewater Treatment
Plant is properly operated and maintained and meeting all the terms and conditions of the permit. Please remember
that violations of the permit are subject to enforcement actions not to exceed $25,000 per day, per violation.
If you have any questions regarding the inspection or this letter, please do not hesitate to contact Mr.
Boone or me at 336-771-5000. Thank you for your cooperation in this matter.
Sincerely,
W. Corey Basinger
Regional Supervisor
Water Quality Regional Operations
Division of Water Resources
Attachments:
CC:
1. BIMS Inspection Report
Central Files
NPD Unit
-A Labs
Attn: Cliff Cain, Operator in Responsible Charge
"106 Short Street
P.O. Box 473
Kernersville; NC 27284

United States Environmental Protection Agency
Form Approved.
EPA Washington, D.rC.20460
OMB No. 2040-0057
Water Compliance Inspection Report
Approval expires 8-31-98
Section A: National Data System Coding (i.e., PCS)
Transaction Code NPDES yr/mo/day Inspection Type
Inspector FacType
1 �N 2 15 1 3 I NCO037311 I11 12 14/11/20 17 18 ICJ
19 I G j 201
21IIII I I III III 1 1I.I I I I I I1I 11 I III I I I I
F I I I II I I f6
Inspection
Work Days Facility Self -Monitoring Evaluation Rating B1 QA
Reserved— --
ti7
70 L 71 I I 72 L N G 73I I 174 75I III I I I I80
LJ
Section B: Facility Data
Name and Location of Facility Inspected (For Industrial Users discharging to POTW, also include
Entry Time/Date
Permit Effective Date
POTW name and NPDES permit Number)
10:OOAM 14/11/20
12/03l01
Creekside Manor Assisted Living
6206 Reidsville Rd
Exit Time/Date
Permit Expiration Date
Kernersville NC 27284
11:00AM 14/11/20
17/02/28
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
Other Facility Data
Clifford Curtis Cain/ORC/336-996-2841/
Name, Address of Responsible Official/Title/Phone and Fax Number
Contacted
James Cheshire,6206 Reidsville Rd Kernersville NC 27284//336-996-2841/
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit Flow Measurement Operations & Maintenance Records/Reports
Self -Monitoring Program Facility Site Review Effluent/Receiving Waters Laboratory
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
(See attachment summary)
Name(s) and Signature(s) of Inspector(s) Agency/Office/Phone and Fax Numbers
Date
Ron Boone WSRO WQ//336-771-4967/
//
/ Z Lt /
Signature of Management Q A Reviewer Agency/Office/Phone andFax Numbers
Date
��
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page#

NPDES yr/mo/day Inspection Type
31 NCO037311 I1 12 14/11/20 17 18 1 r l
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
Page#

Permit: NCO037311 Owner -Facility: Creekside Manor Assisted Living
Inspection Date: 11/20/2014 Inspection Type: Compliance Evaluation
Permit
Yes No NA NE
(If the present permit expires in 6 months or less). Has the permittee submitted anew
❑ .
❑E
❑
application?
Is the facility as described in the permit?
E
❑
❑
❑
# Are there any special conditions for the permit?
❑
0
❑
❑
Is access to the plant site restricted to the general public?
0
❑
❑
❑
Is the inspector granted access to all areas for inspection?
0
❑
❑
❑
Comment: None
Record Keeping
Yes No NA NE
Are records kept and maintained as required by the permit?
❑
❑
❑
Is all required information readily available, complete and current?
N
❑
❑
❑
Are all records maintained for 3 years (lab. reg. required 5 years)?
0
❑
❑
❑
Are analytical results consistent with data reported on DMRs?
E
❑
❑
❑
Is the chain -of -custody complete?
❑
❑
❑
Dates, times and location of sampling
Name of individual performing the sampling
Results of analysis and calibration
Dates of analysis
Name of person performing analyses
Transported COCs
Are DMRs complete: do they include all permit parameters?
E
❑
❑
❑
Has the facility submitted its annual compliance report to users and DWQ?
❑
❑
❑
(If the facility is = or> 5 MGD permitted flow) Do they operate 24/7 with a certified operator
❑
❑
E
❑
on each shift?
Is the ORC visitation log available and current?
E
❑
❑
❑
Is the ORC certified at grade equal to or higher than the facility classification?
0
❑
❑
❑
Is the backup operator certified at one grade less or greater than the facility classification?
❑
❑
❑
Is a copy of the current NPDES permit available on site?
0
❑
❑
❑
Facility has copy of previous year's Annual Report on file for review?
❑
❑
011
Comment: None
Laboratory Yes No NA NE
Are field parameters performed by certified personnel or laboratory? E ❑ ❑ ❑
Are all other parameters(excluding field parameters) performed by a certified lab? 0 ❑ ❑ ❑
Page# 3

Permit: NCO037311 Owner - Facility: Creekside Manor Assisted Living
Inspection Date: 11/20/2014 Inspection Type: Compliance Evaluation
Laboratory
Yes No NA NE
# Is the facility using a contract lab?
❑
❑
❑
# Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees
❑
❑
❑
N
Celsius)?
Incubator (Fecal Coliform) set to 44.5 degrees Celsius+/- 0.2 degrees?
❑
❑
❑
0
Incubator (BOD) set to 20.0 degrees Celsius +/-1.0 degrees?
❑
❑
❑
0
Comment: None
Effluent Sampling
Yes No NA NE
Is composite sampling flow proportional?
❑
❑
❑
Is sample collected below all treatment units?
❑
❑
❑
Is proper volume collected?
❑
❑
❑
Is the tubing clean?
❑
❑
N
❑
# Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees
❑
❑
❑
❑
Celsius)?
Is the facility sampling performed as required by the permit (frequency, sampling type
❑
❑
❑
❑
representative)?
Comment: None
Upstream / Downstream Sampling Yes No NA NE
Is the facility sampling performed as required by the permit (frequency, sampling type, and N ❑ ❑ ❑
sampling location)?
Comment: None
Flow Measurement - Influent
Yes No NA NE
# Is flow meter used for reporting?
N
❑
❑
❑
Is flow meter calibrated annually?
❑
❑
0
❑
Is the flow meter operational?
N
❑
❑
❑
(If units are separated) Does the chart recorder match the flow meter?
❑
❑
0
❑
Comment: City water meter
Bar Screens
Yes No NA NE
Type of bar screen
a.Manual
b.Mechanical
❑
Page# 4
e

Permit: NCO037311
Inspection Date: 11/20/2014
Owner - Facility: Creekside Manor Assisted Living
Inspection Type: Compliance Evaluation
Bar Screens
Yes No NA NE
Are the bars adequately screening debris?
❑
❑
❑
Is the screen free of excessive debris?
N
❑
❑
❑
Is disposal of screening in compliance?
0
❑
❑
❑
Is the unit in good condition?
E
❑
❑
❑
Comment: None
Aeration Basins
Yes No NA NE
Mode of operation
Ext. Air
Type of aeration system
Diffused
Is the basin free of dead spots?
❑
❑
❑
Are surface aerators and mixers operational?
❑ ❑
0❑
Are the diffusers operational?
S ❑
❑
❑
Is the foam the proper color for the treatment process?
❑
❑
❑
Does the foam cover less than 25% of the basin's surface?
❑
❑
❑
Is the DO level acceptable?
❑ ❑
❑
Is the DO level acceptable?(1.0 to 3.0 mg/I)
❑ ❑
❑
Comment: None
Secondary Clarifier
Yes No NA NE
Is the clarifier free of black and odorous wastewater?
❑
❑
❑
Is the site free of excessive buildup of solids in center well of circular clarifier?
❑
❑
0
❑
Are weirs level?
N
❑
❑
❑
Is the site free of weir blockage?
❑
❑
❑
Is the site free of evidence of short-circuiting?
N
❑
❑
❑
Is scum removal adequate?
❑
❑
❑
Is the site free of excessive floating sludge?
❑
❑
❑
Is the drive unit operational?
❑
❑
❑
Is the return rate acceptable (low turbulence)?
❑
❑
❑
Is the overflow clear of excessive solids/pin floc?
❑
0
❑
❑
Is the sludge blanket level acceptable? (Approximately'/ of the sidewall depth)
❑
❑
❑
N,
Comment: The only thing noted was a laver of sludge on top of the clarifier and pin floc escaping over
the weir. Mr. Cain stated he thought the sludge was too old and would immediately
start
wasting more to try to establish a younger sludge in the system. There were no other
discrepancies or violations noted. The plant appears to be operated and maintained well
Page# 5

Permit: NCO037311
Owner - Facility: Creekside Manor Assisted Living
Inspection Date: 11/20/2014
Inspection Type: Compliance Evaluation
Pumps-RAS-WAS
Yes No NA NE
Are pumps in place?
S
❑
❑
❑
Are pumps operational?
0
❑
❑
❑
Are there adequate spare parts and supplies on site?
S
❑
❑
❑
Comment: None
Disinfection -Tablet
Yes No NA NE
Are tablet chlorinators operational?
0
❑
❑
❑
Are the tablets the proper size and type?
■
❑
❑
❑
Number of tubes in use?
2
Is the level of chlorine residual acceptable?
❑
❑
❑
Is the contact chamber free of growth, or sludge buildup?
0
❑
❑
❑
Is there chlorine residual prior to de -chlorination?
❑
❑
❑
E
Comment: None
De -chlorination
Yes No NA NE
Type of system ?
Tablet
Is the feed ratio proportional to chlorine amount (1 to 1)?
❑
❑
❑
Is storage appropriate for cylinders?
0
❑
❑
❑
# Is de -chlorination substance stored away from chlorine containers?
0
❑
❑
❑
Are the tablets the proper size and type?
❑
❑
❑
Comment: None
Are tablet de -chlorinators operational?
E
❑
❑
❑
Number of tubes in use?
2
Comment: None
Effluent Pipe Yes No NA NE
Is right of way to the outfall properly maintained? 0 ❑ ❑ ❑
Are the receiving- water free of foam other than trace amounts and other debris? 0 ❑ ❑ ❑
If effluent (diffuser pipes are required) are they operating properly? ❑ ❑ e ❑
Comment: None
Operations & Maintenance Yes No NA NE
Is the plant generally clean with acceptable housekeeping? E ❑ ❑ ❑
Page# 6
e

Permit: NCO037311 Owner -Facility: Creekside Manor Assisted Living
Inspection Date: 11/20/2014 Inspection Type: Compliance Evaluation
Operations & Maintenance Yes No NA NE
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable 0 ❑ ❑ ❑
Solids, pH, DO, Sludge Judge, and other that are applicable?
Comment: None
Page# 7

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name: li GI1/�� r� L l_..0
Mailing Address: t1L•®lll I\-i' �Ci�ii��� 1�,
City: 4C Nk rSP V, .1 V State: 1 �Zip: �a� - Phone #: ( 1
Email addres :
Signature: ioryia �c.P7 Date: 11,11)1)4
Facility Na ���Qid�i t �i. ► A&4 `J J �14 Permit #: r10 0:03 f
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Tyne/Grade:
Biological WWTP �_ Surface Irrigation
Physical/Chemical Land Application
Collection System
Operator in Responsible Charge (ORC)
Print Full Name:
Certificate Type / Grade / Number: � � I I . Work Phone #: m io) qq La —a2 Z
Signature: Date:__01.94nk
"I certify that I agree to my designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the rules
and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Q cy--) d1 F!r ►' U
Certificate Type /Grade /Number: / Work Phone #: (33uc) �1 QL
Signature: Date: (00I�
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
.................................................................................................................................................
Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: tia�iT:cetam�nlii"��o
Mail or fax a copy to the Asheville
appropriate Regional Office: 2090 US Hwy 70
Swannanoa 28778
Fax: 828.299,.7043
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
585 Waughtown St
Winston-Salem 27107
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 03-2014

Facility Name: Qj'Qcf�➢j-c & rlo � s l S�-�C! Liv, �''� Permit #• �. o Q
Back -Up Operator in
Responsible Charge (BU ORC) Print Full Name: 6-K\ '_T�kr V) P_
,,.A p
Certificate Type / Grade / Number: lid_ 3 �. Rt) Work Phone
Signature: vv Date: 1116
"1 certify that 1 agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Work Phone #:
Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Work Phone #: ( )
Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Work Phone #: ( )
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
........................................................................................................................................................................
Revised 03-2014

A�,a.
North Carolina Department of Environment and natural Resources
Division of Water Resources
Water Quality Regional Operations Section
Pat McCrory Thomas A. Reeder
Governor Director
February 11, 2014
Winston-Salem/Forsyth County Board of Education
Attn: Barry Smith, Superintendent
4897 Lansing Drive
Winston Salem, NC 27105
Subject: NOTICE OF VIOLATION
NOV-2014-LV-0052
Permit No. NCO034827
Old Richmond Elementary School
Forsyth County
Dear Mr Smith:
John E. Skvarla, III
Secretary
A review of Old Richmond Elementary School's monitoring report for October 2013 showed the following
violations:
Parameter
Date
Limit Value
Reported Value
Limit Type
Flow, in conduit or thru treatment plant
10/31/13
0.006 mgd
0.02 mgd
Monthly
Average
Exceeded
Remedial actions, if not already implemented, should be taken to correct the above noncompliance problem.
Please be aware that violations of your NPDES permit could result in enforcement action by the Division of
Water Resources for this and any additional violations of State law.
If you should have any questions, please do not hesitate to contact Ron Boone at [phone].
cc: SWP — Central Files
+'MOST .
North Carolina Division of Water Resources, Winston-Salem Regional Office
Location: 585 Waughtown St. Winston-Salem, North Carolina 27107
Phone: [phone] FAX: [phone] Customer Service: 1-877-623-6748
Internet: www.ncwater.org
Sincerely,
W. Corey Basinger
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources
NorthCar o ina
An Equal Opportunity 1 Affirmative Action Employer

• Facility:
Parameter
(6en1
Date Parameter
Date Parameter
r Violations/Staff Remarks:
fee 61— e�
DMR RevWw Record
Permit No.: 3 27 Pipe No.: MonthNear:
Monthly Average Violations
Permit Limit DMR Value % Over Limit Action
Weekly/Daily Violations
Permit Limit Limit Type DMR Value % Over Limit Action
Monitoring Frequency Violations
Permit Frequency . Values Reported
# of Violations Action
supervisor Remarks:
w6(( �" �- �W4- LV - oo.5z
Completed by:
Assistant Regional
Supervisor Sign Off:
Regional Supervisor Sign
Off:
Date: 1 z3
Date:
Date:

NC0034827
Old Richmond Elementary School
Limit Violation
BOD, 5-Day (20 Deg. C) - Concentration
Nitrogen, Ammonia Total (as N) - Concentration
Monitoring Violation

Flow, in conduit or thru treatment plant

NPDES APPLICATION - FORM D
For privately owned treatment systems treating 100% domestic wastewaters <1.0 MGD
Mail the complete application to: -
t;�D�IVf�D
N. C. Department of Environment and Natural Resourc s A ,. , ENR
Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617 AUG 08 20-07
Y:nstun-�aiem
NPDES Permit 0000373ii Regional Office
If you are completing this form in computer use the TAB key or the up - down arrows to move from one
field to the next. To check the boxes, click your mouse on top of the box. Otherwise, please print or type.
1. Contact Information:
Owner Name
Hammond Properties
Facility Name
Creekside Manor Rest Home
Mailing Address
P. O. 485
City
Kernersville
State / Zip Code
NC/ 27285-0485
Telephone Number
[phone]
Fax Number
[phone]
e-mail Address
2. Location of facility producing discharge:
Check here if same address as above ❑
Street Address or State Road 6206 Reidsville Rd
City Kernersville
State / Zip Code NC/27285
County Forsyth
3. Operator Information:
Name of the firm, public organization or other entity that operates the facility. (Note that this is not
referring to the Operator in Responsible Charge or ORC)
Name Research And Analytical Laboratories, Inc.
Mailing Address P. O. Box 473
City Kernersville
State / Zip Code NC/27284
Telephone ,Number [phone]
Fax Number [phone]
1 of 4 Form-D 1106

NPDES APPLICATION - FORM D
For privately owned treatment systems treating 100% domestic wastewaters <1.0 MGD
4. Description of wastewater:
Facility Generating Wastewater(check all that apply
Industrial
❑
Number of Employees
Commercial
❑
Number of Employees
Residential
❑
Number of Homes
School
❑
Number of Students/Staff
Other
®
Explain: RestHome
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Population served:
5. Type of collection system
® Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points 1
Outfall Identification number(s) 001
Is the outfall equipped with a diffuser? ❑ Yes Z Wo
7. Name of receiving stream(s) (Provide a map showing the exact location of each outfallr
unnamed tributary to Belews Creek
8. Frequency of Discharge: ® Continuous ❑ Intermittent
If intermittent:
Days per week discharge occurs: 7 Duration:
9. Describe the treatment system
List all installed components, including capacity, provide design removal for BOD, TSS, nitrogen and
phosphorus. If the space provided is not sufficient, attach the description of the treatment system in a
separate sheet of paper.
0.01 wastewater facility consisting of the following:
-aeration basin with diffused air
-clarifier
-tablet chlorination
-chlorine contact basin
-sludge holding tank
2 of 4 Fnrm-n 11os

NPDES APPLICATION - FORM D
For privately owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow 0.010 MGD
Annual Average daily flow 0.004 MGD (for the previous 3 years)
Maximum daily flow 0.007 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes ® No
12. Effluent Data
Provide data for the parameters listed. Fecal Coliform, Temperature and pH shall be grab samples, for all other
parameters 24-hour composite sampling shall be used. Effluent testing data must be based on at least three samples
and must be no more than four and one half years old.
Parameter
Daily
Maximum
Monthly
Average
Units of
Measurement
Number of
Samples
Biochemical Oxygen Demand
(BODS)
12.0
3.0
mg/l
Fecal Coliform
> 12,000
62.0
col/ 100mis
Total Suspended Solids
34.0
13.4
mg/l
Temperature (Summer)
24.0
21.0
°C
Temperature (Winter)
16.0
12.4
°C
pH
6.74
6.13-6.74
SU
13. List all permits, construction approvals and/or applications:
Type Permit Number Type
Hazardous Waste (RCRA) NESHAPS (CAA)
UIC (SDWA) Ocean Dumping (MPRSA)
NPDES NCO037311 Dredge or fill (Section 404 or CWA)
PSD (CAA) Special Order of Consent (SOC)
Non -attainment program (CAA) Other
14. APPLICANT CERTIFICATION
Permit Number
I certify that I am familiar with the information contained in the application and that to the
best of my knowledge and belief such information is true, complete, and accurate.
James M. Cheshire Authorized Agent
Printed name of Person Signing Title
3 of 4 Form-D 1 /06

NPDES APPLICATION - FORM D
For privately owned "r atment systems treating 100% domestic wastewaters <1.0 MGD
Signat of Applicant ' Date
North C lina General Statute 143-215.6 (b)(2) states: Any person who knowingly makes any false statement
representVion, or certification in any application, record, report, plan, or other document files or required to be
maintained under Article 21 or regulations of the Environmental Management Commission implementing that Article, or
who falsifies, tampers with, or knowly renders inaccurate any recording or monitoring device or method required to be
operated or maintained under Article 21 or regulations of the Environmental Management Commission implementing
that Article, shall ,be guilty of a misdemeanor punishable by a fine not to exceed $25,000, or by imprisonment not to
exceed six months, or by both. (18 U.S.C. Section 1001 provides a punishment by a fine of not more than $25,000 or
imprisonment not more than 5 years, or both, for a similar offense.)
4 of 4 Form-D 1 /06

SLUDGE MANAGEMENT PLAN
CREEKSIDE MANOR WASTEWATER TREAMENT PLANT
NPDES PERMIT NO. NC0037311
Sludge from the Creekside Manor wastewater treatment plant are disposed of in the
following way:
Solids are collected in the sludge holding tank and digested
aerobically. The excess solids are periodically pumped and
halved by a licensed septic pumper contractor and disposed
of at the City of Greensboro wastewater treatment plant.

Discharge Location
sa°
_ J
-- _.
J�4
0
_ Facility Information
de: 3612'49' Sub -Basin: 03-02-01
rude: 80 03'49'
ame: Belews Creek
a Class: C
firm Stream: 'UTto Belews Creek
Facility
Location
«-.���-yaw„.;
-`'-N
Pierce
North
'Management Group - Creckside Manor ?testHome
NCO07.411
Forsyth County
'forsyt�i Coursty

—':t
IGNITED STATES F�OSTACERVICE
P11 .'1 �_ .
First -Class Mail
Postage & Fees Paid
USPS
Permit No. G-10
• Sender: Please print your name, address, and ZIP+4 in this box •
DIVISION OF WATER RESOURCES
Water Quality Regional Operations
450 West Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
,_..:-:..:::; r _........ i,1i,111�1III'

■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
AiiegianCe r1eawicare Invesiors, LLI.
Attn: William R. Hammonds
PO Box 485
Kernersviiie, NC 27285-0485
2. Article Number 7013
(Transfer from ser---y
PS Form 3811, February 2004
A. Si ature
❑ Agent
❑ Addressee
e&e,vby'( Afinted N C. Date of Delivery
D. Is delivgry address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3.\Sery ice Type
VCertified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
1710 0002 1865 5320
Domestic Return Receipt ') — I q - / cz 102595-02-M-154