NC0037311_Renewal (Application)_20220505

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
Form
NPDES
NC Department of Environmental Quality - Application for NPDES Permit to Discharge Wastewater
MINOR SEWAGE FACILITIES (Before completing this form, please read the instructions. Failure to follow
the instructions may result in denial of the application.)
Facility Information
N
e
IC APPLICATION INFORMATION FOR ALL APPLICANTS (40 CFR 122.21(j)(1) and (9))
Facility name
Creekside Manor Rest Home
Mailing address (street or P.O. box)
P.O. Box 1487
City or town
Kernersville
State
NC
ZIP code
27285
Contact name (first and last)
William Hammonds
Title
Owner
Phone number
[phone]
Email address
[e-mail]
Location address (street, route number, or other specific identifier)
6206 Reidsville Rd.
❑ Same as mailing
address
City or town
Kernersville
State
NC
ZIP code
27285
Is this application for a facility that has yet to commence discharge?
❑ Yes 4 See instructions on data submission
requirements for new dischargers.
✓
No
Applicant Information
1.3
Is applicant
✓
different from entity listed under Item 1.1 above?
Yes ❑ No 4 SKIP to Item 1.4.
Applicant name
Pace Analytical Services
Applicant address (street or P.O. box)
1377 South Park Dr.
City or town
Kernersville
State
NC
ZIP code
27284
Contact name (first and last)
Clifford Cain
Title
Operator
Phone number
[phone]
Email address
[e-mail]
1.4
Is the applicant the facility's owner, operator,
❑ Owner
✓
or both? (Check only one response.)
Operator ❑ Both
1.5
To
✓
which entity should the NPDES permitting
Facility
•
authority send correspondence? (Check only one response.)
Applicant ❑ Facility and applicant
(they are one and the same)
Existing Environmental Permits
1.6
Indicate
number
below any existing environmental
for each.)
permits.
(Check all that apply and print or type the corresponding permit
Existing Environmental Permits
p
NPDES (discharges to surface
water)
NC0037311
•
RCRA (hazardous waste)
❑ UIC (underground injection
control)
❑ PSD (air emissions)
❑ Nonattainment program (CAA)
•
NESHAPs (CAA)
❑ Ocean dumping (MPRSA)
❑ Dredge or fill (CWA Section
404)
❑ Other (specify)
Page 1

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
Collection System and Population Served
1.7
Provide the collection system information requested below for the treatment works.
Municipality
Served
Population
Served
Collection System Type
(indicate percentage)
Ownership Status
100 % separate sanitary sewer
0 Own O Maintain
MHP
60
% combined storm and sanitary sewer
0 Own 0 Maintain
0 Unknown
❑ Own 0 Maintain
% separate sanitary sewer
❑ Own 0 Maintain
% combined storm and sanitary sewer
0 Own 0 Maintain
❑ Unknown
0 Own 0 Maintain
% separate sanitary sewer
0 Own 0 Maintain
% combined storm and sanitary sewer
0 Own ❑ Maintain
❑ Unknown
0 Own 0 Maintain
% separate sanitary sewer
0 Own ❑ Maintain
% combined storm and sanitary sewer
0 Own 0 Maintain
Total
Population
Served
60
0 Unknown
0 Own ❑ Maintain
Separate Sanitary Sewer System
Combined Storm and
Sanitary Sewer
Total percentage of each type of
sewer line (in miles)
o
100 /0
0
y0
Indian Country
1.8
Is the treatment works located in Indian
❑ Yes
Country?
✓
No
1.9
Does the facility discharge to a receiving
❑ Yes
water that flows through
✓
Indian Country?
No
Design and Actual
Flow Rates
1.10
Provide design and actual flow rates
in the designated spaces.
Design Flow Rate
0.010 mgd
Annual Average Flow Rates (Actual)
Two Years Ago
Last Year
This Year
0.006 mgd
0.005 mgd
0.004 mgd
Maximum Daily Flow Rates (Actual)
Two Years Ago
Last Year
This Year
0.012 mgd
0.007 mgd
0.006 mgd
Discharge Points
by Type
1,11
Provide the total number of effluent discharge points to waters of the State of North Carolina by type.
Total Number of Effluent Discharge Points by Type
Treated Effluent
Untreated Effluent
Combined Sewer
Overflows
Bypasses
Constructed
Emergency
Overflows
1
Page 2

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
Outfalls and Other Discharge or Disposal Methods
Outfalls Other Than to Waters of the State of North Carolina
1.12
Does the POTW
for discharge
discharge wastewater to basins, ponds,
to waters of the State of North Carolina?
or other
surface impoundments that do not have outlets
4 SKIP to Item 1.14.
■ Yes
0 No
1.13
Provide the location of each surface impoundment and associated discharge information in the table below.
Surface Impoundment Location and Discharge Data
Location
Average Daily Volume
Discharged to Surface
Impoundment
Continuous or Intermittent
(check one)
gpd
❑ Continuous
❑ Intermittent
gpd
❑ Continuous
❑ Intermittent
gpd
0 Continuous
❑ Intermittent
1.14
Is wastewater
applied to land?
4 SKIP to Item 1.16.
• Yes
III No
1.15
Provide the land application site and discharge data requested below.
Land Application Site and Discharge Data
Location
Size
Average Daily Volume
Applied
Continuous or
Intermittent
(check one)
acres
d
gip"'
0 Continuous
❑ Intermittent
acres
d
gpd
0 Continuous
❑ Intermittent
acres
gp d
❑ Continuous
❑ Intermittent
1.16
Is effluent transported
to another facility for
treatment prior to
discharge?
4 SKIP to Item 1.21.
• Yes
!rI
No
1.17
Describe the means by which the effluent is transported (e.g., tank truck, pipe).
1.18
Is the effluent
transported by a party other than
the applicant?
4 SKIP to Item 1.20.
• Yes
0
No
1.19
Provide information on the transporter below.
Transporter Data
Entity name
Mailing address (street or P.O. box)
City or town
State
ZIP code
Contact name (first and last)
Title
Phone number
Email address
Page 3

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
Outfalls and Other Discharge or Disposal Methods Continued
1.20
In the table below, indicate the name, address, contact information, NPDES number, and average daily flow rate of the
receiving facility.
Receiving Facility Data
Facility name
Creekside Manor Rest Home
Mailing address (street or P.O. box)
P.O. Box 1487
City or town
Kernersville
State
NC
ZIP code
27285
Contact name (first and last)
William Hammonds
Title
Owner
Phone number
[phone]
Email address
[e-mail]
NPDES number of receiving facility (if any) El None
Average daily flow rate 0.005 mgd
1.21
Is the
not
■
wastewater disposed of in a manner other than
have outlets to waters of the State of North Carolina
Yes
51
those a
(e.g.,
No
ready mentioned in Items 1.14 through 1.21 that do
underground percolation, underground injection)?
4 SKIP to Item 1.23.
1.22
Provide
information in the table below on these other disposal methods.
Information on Other Disposal Methods
Description
Disposal
Method
Location of
Disposal Site
Size of
Disposal Site
Annual Average
Daily Discharge
Volume
Continuous or Intermittent
(check one)
acres
gp d
0 Continuous
0 Intermittent
acres
gp d
0 Continuous
0 Intermittent
acres
gp d
0 Continuous
0 Intermittent
Variance
Requests
1.23
Do
Consult
12
you intend to request or renew one or more of the
with your NPDES permitting authority to determine
Discharges into marine waters (CWA �
Section 301(h))
Not applicable
variances authorized at 40 CFR 122.21(n)? (Check all that apply.
what information needs to be submitted and when.)
Water quality related effluent limitation (CWA Section
302(b)(2))
Contractor Information
1.24
Are
the
•
any operational or maintenance aspects (related to
responsibility of a contractor?
Yes 0
wastewater treatment and effluent quality) of the treatment works
No *SKIP to Section 2.
1.25
Provide location and contact information for each contractor in addition to a description of the contractor's operational
and maintenance responsibilities.
Contractor Information
Contractor 1
Contractor 2
Contractor 3
Contractor name
(company name)
Mailing address
(street or P.O. box)
City, state, and ZIP
code
Contact name (first and
last)
Phone number
Email address
Operational and
maintenance
responsibilities of
contractor
Page 4

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
SECTION 2. ADDITIONAL INFORMATION
(40 CFR 122.21(j)(1) and
(2))
o
a�
o
Outfalls to Waters of the State of North Carolina
2.1
Does the treatment
works have a design
flow greater
than or equal to 0.1 mgd?
No -9 SKIP to Section 3.
• Yes
✓
Inflow and Infiltration
2.2
Provide the treatment works' current average daily volume of inflow
and infiltration.
Average Daily Volume of Inflow and Infiltration
gpd
Indicate the steps the facility is taking to minimize inflow and infiltration.
Topographic
Map
2.3
Have you attached a topographic map to this application that contains all the required information? (See instructions for
specific requirements.)
❑ Yes ❑ No
Flow
Diagram
2.4
Have you attached a process flow diagram or schematic to this application that contains all the required information?
(See instructions for specific requirements.)
❑ Yes ❑ No
Scheduled Improvements and Schedules of Implementation
2.5
Are improvements to the facility scheduled?
❑ Yes ❑ No 4 SKIP to Section 3.
Briefly list and describe the scheduled improvements.
1.
2.
3.
4.
2.6
Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Improvements
Scheduled
Improvement
(from above)
Affected
Outfalls
(list outfall
number)
Begin
Construction
(MM/DD/YYYY)
End
Construction
(MM/DD/YYYY)
Begin
Discharge
(MM/DDIYYYY)
Attainment of
Operational
Level
(MM/DD/YYYY)
1.
2.
3.
4.
2.7
Have appropriate permits/clearances concerning other federal/state requirements been obtained? Briefly explain your
response.
❑ Yes ❑ No ❑ None required or applicable
Explanation:
Page 5

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
Description of Outfalls
. - r A • •
Provide the following
I 1 I ■ 1- 0 - 4,* to
information for each outfall. (Attach additional sheets if you have more than three outfalls.)
Outfall Number 001
Outfall Number
Outfall Number
State
NC
County
Forsyth
City or town
Kernersville
Distance from shore
2.5 ft.
ft.
ft.
Depth below surface
3 ft.
ft.
ft.
Average daily flow rate
0.005 mgd
mgd
mgd
Latitude
36° 12' 50"
°
° ' "
Longitude
80° 3' 49"
° "'
Seasonal or Periodic Discharge Data
3.2
Do
•
any of the outfalls described
Yes
under Item 3.1 have seasona
or
periodic
✓
discharges?
No -4 SKIP to Item 3.4.
3.3
If so, provide the following information
for each applicable outfall.
Outfall Number
Outfall Number
Outfall Number
Number of times per year
discharge occurs
Average duration of each
discharge (specify units)
Average flow of each
discharge
mgd
mgd
mgd
Months in which discharge
occurs
Diffuser Type
3.4
Are any of the outfalls listed under Item 3.1 equipped with a diffuser?
❑ Yes
✓
No 4 SKIP to Item 3.6.
3.5
Briefly describe the diffuser type at each applicable outfall.
Outfall Number
Outfall Number
Outfall Number
Waters of
the U.S.
3.6
Does the treatment works discharge or plan to discharge wastewater
one or more discharge points?
❑ Yes
NI
to waters of the State of North Carolina from
No 4 SKIP to Section 6.
Page 6

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
Receiving Water Description
3.7
Provide the receiving water and related information (if known) for each outfall.
Outfall Number
Outfall Number
Outfall Number
Receiving water name
Name of watershed, river,
or stream system
U.S. Soil Conservation
Service 14-digit watershed
code
Name of state
management/river basin
U.S. Geological Survey
8-digit hydrologic
cataloging unit code
Critical low flow (acute)
cfs
cfs
cfs
Critical low flow (chronic)
cfs
cfs
cfs
Total hardness at critical
low flow
mg/L of
CaCO3
mg/L of
CaCO3
mglL of
CaCO3
Treatment Description
3.8
Provide the following information
describing the treatment provided for discharges from each outfall.
Outfall Number
Outfall Number
Outfall Number
Highest Level of
Treatment (check all that
apply per outfall)
❑ Primary
0 Equivalent to
secondary
❑ Secondary
O Advanced
O Other (specify)
0 Primary
0 Equivalent to
secondary
0 Secondary
0 Advanced
0 Other (specify)
0 Primary
0 Equivalent to
secondary
0 Secondary
0 Advanced
0 Other (specify)
Design Removal Rates by
Outfall
BOD5 or CBOD5
%
%
%
TSS
%
%
%
Phosphorus
0 Not applicable
%
0 Not applicable
%
0 Not applicable
o
/o
Nitrogen
0 Not applicable
%
0 Not applicable
,/o
0 Not applicable
Other (specify)
0 Not applicable
%
0 Not applicable
%
0 Not applicable
%
Page 7

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
Effluent Testing Data Treatment Description Continued
3.9
Describe the type of disinfection used for the effluent from each outfall in the table below. If disinfection varies by
season, describe below.
Outfall Number
Outfall Number
Outfall Number
Disinfection type
Seasons used
Dechlorination used?
•
Not applicable
■ Not applicable
■ Not applicable
■
Yes
■ Yes
■ Yes
•
No
• No
■ No
3.10
Have you completed monitoring for all Table A parameters and attached the results to the application package?
• Yes
• No
3.11
Have you conducted any WET tests during the 4.5 years prior to the date of the application on any of the facility's
discharges or on any receiving water near the discharge points?
• Yes
■ No 4 SKIP to Item 3.13.
3.12
Indicate the number of acute and chronic WET tests conducted since the last permit reissuance of the facility's
discharges by outfall number or of the receiving water near the discharge points.
Outfall Number
Outfall Number
Outfall Number
Acute
Chronic
Acute
Chronic
Acute
Chronic
Number of tests of discharge
water
Number of tests of receiving
water
3.14
Does the POTW use chlorine for disinfection, use chlorine elsewhere in the treatment process, or otherwise have
reasonable potential to discharge chlorine in its effluent?
• Yes 4 Complete Table B, including chlorine.
• No 4 Complete Table B, omitting chlorine.
3.15
Have you completed monitoring for all applicable Table B pollutants and attached the results to this application
package?
• Yes
■ No
Have you completed monitoring for all applicable Table D pollutants required by your NPDES permitting authority and
3.18
attached the results
to this application package?
No
sampling required by NPDES
authority.
MI Yes
additional
•
permitting
Page 8

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
Effluent Testing Data Continued
3.19
Has the POTW
or (2) at least
conducted either (1) minimum of four quarterly WET tests for one year preceding this permit application
four annual WET tests in the past 4.5 years?
❑ No 4 Complete tests and Table E and SKIP to
Item 3.26.
• Yes
3.20
Have you previously submitted the results of the above
❑ Yes
tests to your NPDES permitting
No Provide
authority?
results in Table E and SKIP to
4
■
Item 3.26.
3.21
Indicate the dates the data were submitted to your NPDES permitting authority and provide a summary of the results.
Date(s) Submitted
(MMODNYYY)
Summary of Results
3.22
Regardless of how you provided your WET testing data to the NPDES permitting authority, did any of the tests result in
toxicity?
❑ Yes ❑ No -3 SKIP to Item 3.26.
3.23
Describe the cause(s) of the toxicity:
3.24
Has the treatment works conducted a toxicity reduction evaluation?
❑ Yes ❑ No 4 SKIP to Item 3.26.
3.25
Provide details of any toxicity reduction evaluations conducted.
3.26
Have you completed Table E for all applicable outfalls
❑ Yes
and attached the results to the application package?
❑ Not applicable because previously submitted
information to the NPDES •ermittin. authori .
Page 9

NPDES Permit Number
NC0037311
Facility Name
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
SECTION 6. CHECKLIST
AND CERTIFICATION STATEMENT (40 CFR 122.22(a) and (d))
Checklist and Certification Statement
6.1
In Column 1 below, mark the sections of Form 2A that you have completed and are submitting with your application. For
each section, specify in Column 2 any attachments that you are enclosing to alert the permitting authority. Note that not
all applicants are required to provide attachments.
Column 1
Column 2
Section 1: Basic Application
request(s)
• w/ variance
■ w/ additional attachments
Information for All Applicants
Section 2: Additional
❑ w/ topographic
map
attachments
■ w/ process flow diagram
•
Information
■ w/ additional
Section 3: Information
• w/ Table
A ❑ w/ Table D
B ❑ w/ additional attachments
C
❑ wl Table
❑ w/ Table
on
Effluent Discharges
Section 4: Not Applicable
Section 5: Not Applicable
Section 6: Checklist
and
w/ attachments
Certification Statement
6.2
Certification Statement
1 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. 1 am aware that there are significant penalties for submitting false information, including the possibility of fine
and imprisonment for knowing violations.
Name (print or type first and last name)
Clifford Cain
Official title
Operator
Signature
end C.ai-y--....
Date signed
1,—,A)----)6121
Page 10

NPDES Permit Number
Facility Name
Outfall Number
NC0037311
Creekside Manor Rest Home
Modified Application Form 2A
Modified March 2021
TABLE A. EFFLUENT PARAMETERS
FOR ALL POTWS
Maximum Daily Discharge
Average Daily Discharge
Analytical
Methods
ML or MDL
(include units)
Pollutant
Value
Units
Value
Units
NSamplest
Biochemical oxygen demand
❑ BODs or 0 CBODs
(report one)
25.8
mg/L
9.29
mg/L
156
varies
0 ML
NA ❑ MDL
Fecal coliform
1050
col/100m1
1.33
col/1o0m1
156
varies
ML
NA ❑❑ MDL
Design flow rate
0.012
mgd
0.005
mgd
780
pH (minimum)
7.0 (minimum)
N/A
pH (maximum)
8.6
Std. Units
Temperature (winter)
20
°C
13.78
°C
109
Temperature (summer)
29
°C
23.3
°C
151
Total suspended solids (TSS)
47
mg/L
9.7
mg/L
156
varies
0 ML
NA MDL
1 Sampling shall be conducted according to sufficiently sensitive test procedures (i.e., methods) approved under 40 CFR 136 for the analysis of pollutants or pollutant parameters or
required under 40 CFR chapter I, subchapter N or 0. See instructions and 40 CFR 122.21(e)(3).
Page 11

11
NC0037311 — Creekside Manor Rest Home
'itude:
36°12'49"
2gitude: 80°03'49"
Quad Name: Belews Creek
Stream Class: C
Receiving Stream: UT to Belews Creek
Sub -Basin: 03-02-01
Hydrologic Unit: 03010103
Forsyth County
[map not to scale]

Sludge Management Plan
Creekside Manor Rest Home WWTP
NPDES Permit No. NC 0037311
Sludge from the Creekside Manor Rest Home wastewater treatment plant are disposed of in the
following manner:
Solids are collected in the sludge holding tank and digested aerobically. The excess solids
are periodically pumped and hauled by Carolina Septic a licensed septic pumper contractor
and disposed of at the City of Greensboro waterwater treatment plant.