NC0037311_Renewal (Application)_20220623

NPDES Permit Number FacilityName Modified Application Form 2A
PP
NC0037311 Creekside Manor Rest Home Modified March 2021
Form NC Department of Environmental Quality-Application for NPDES Permit to Discharge Wastewater
NPDES MINOR SEWAGE FACILITIES(Before completing this form,please read the instructions.Failure to follow
the instructions ma result in denial of the application.)
SECTION 1.BASIC APPUCATION INFORMATION FOR ALL APPLICANTS(40 CFR 122.21(j)(1)and(9))
1.1 Facility name
Creekside Manor Rest Home
Mailing address(street or P.O.box)
P.O.Box 1487
City or town State ZIP code
o Kernersville NC 27285
Contact name(first and last) Title Phone number Email address
o William Hammonds Owner [phone] [e-mail]
Location address(street,route number,or other specific identifier) ❑ Same as mailing address •
6206 Reidsville Rd.
LL
City or town State ZIP code
Kernersville NC 27285
1.2 Is this application for a facility that has yet to commence discharge?
❑ Yes 4 See instructions on data submission ❑ No
requirements for new dischargers.
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.
o City or town State ZIP code
Kernersville NC 27284
Contact name(first and last) Title Phone number Email address
a Clifford Cain Operator [phone] [e-mail]
1.4 Is the applicant the facility's owner,operator,or both?(Check only one response.)
❑ Owner ID Operator ❑ Both
1.5 To which entity should the NPDES permitting authority send correspondence?(Check only one response.)
❑� Facility ❑ Applicant Facility and applicant
(they are one and the same)
1.6 Indicate below any existing environmental permits.(Check all that apply and print or type the corresponding permit
number for each.)
9
Existin Environmental Permits
d
0 NPDES(discharges to surface ❑ RCRA(hazardous waste) ❑ UIC(underground injection
water) control)
E NC0037311
o ❑ PSD(air emissions) ❑ Nonattainment program(CAA) 0 NESHAPs(CM)
rn
.N ❑ Ocean dumping(MPRSA) ❑ Dredge or fill(CWA Section ❑ Other(specify)
404)
Page 1

NPDES Permit Number Facility Name t,odfied Application Form 2A
NC0037311 Creekside Manor Rest Home Modified March 2021
1.7 Provide the collection system information requested below for the treatment works.
Municipality Population Collection System Type Ownership Status
Served Served (indicate percentage)
1o0 %separate sanitary sewer 0 Own 0 Maintain
ZMHP 60 %combined storm and sanitary sewer ❑ Own ❑ Maintain
O ❑ Unknown ❑ Own ❑ Maintain
cn
co %separate sanitary sewer ❑ Own ElMaintain
9
%combined storm and sanitary sewer ❑ Own 0 Maintain
S.a 0 Unknown ❑ Own ❑ Maintain
a %separate sanitary sewer ElOwn 0 Maintain
c %combined storm and sanitary sewer ❑ Own 0 Maintain
`O 0 Unknown ❑ Own 0 Maintain
E %separate sanitary sewer El Own ❑ Maintain
> %combined storm and sanitary sewer ❑ Own 0 Maintain
e El Unknown El Own ❑ Maintain
o Total
Population 60
c�i Served
Separate Sanitary Sewer System Combined Storm and
Sanitary Sewer
Total percentage of each type of ° °
sewer line(in miles) 100 �0 �0
Z 1.8 Is the treatment works located in Indian Country?
c
o ❑ Yes 0 No
U
A 1.9 Does the facility discharge to a receiving water that flows through Indian Country?
c 0 Yes ❑ No
1.10 Provide design and actual flow rates in the designated spaces. Design Flow Rate
0.010 mgd
To
€n Annual Average Flow Rates(Actual)
aco
2 Two Years Ago Last Year This Year
c
rx
Coco
0.006 mgd 0.005 mgd 0.004 mgd
in Maximum Daily Flow Rates(Actual)
c3 Two Years Ago Last Year This Year
0.012 mgd 0.007 mgd 0.006 mgd
o 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
a o. Constructed
Combined Sewer
Treated Effluent Untreated Effluent Overflows Bypasses Emergency
- Overflows
N_
a 1
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NPDES Permit Number Facility Name Modified Application Form 2A
NC0037311 Creekside Manor Rest Home Modified March 2021
Outfalls Other Than to Waters of the Stab)of North Carolina
1.12 Does the POTW discharge wastewater to basins,ponds,or other surface impoundments that do not have outlets
for discharge to waters of the State of North Carolina?
O Yes ❑� No 4 SKIP to Item 1.14.
1.13 Provide the location of each surface impoundment and associated discharge information in the table below.
Surface Impoundment Location and Discharge Data
Average Daily Volume Continuous or Intermittent
Location Discharged to Surface (check one)
Impoundment
❑ Continuous
gPd ❑ Intermittent
❑ Continuous
gpd ❑ Intermittent
O Continuous
gpd ❑ Intermittent
r 1.14 Is wastewater applied to land?
❑ Yes ❑✓ No 4 SKIP to Item 1.16.
c 1.15 Provide the land application site and discharge data requested below.
n Land Application Site and Discharge Data
o Average Daily Volume
Continuous or
Location Size Applied Intermittent
(check one)
❑ Continuous
acres gpd ❑ Intermittent
0
acres gpd ❑ Continuous
❑ Intermittent
acres d 0 Continuous
gp ❑ Intermittent
• 1.16 Is effluent transported to another facility for treatment prior to discharge?
o ❑ Yes m No 4 SKIP to Item 1.21.
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?
❑ Yes 0 No 9 SKIP to Item 1.20.
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 Facility Name Modfied Application Form 2A
NC0037311 Creekside Manor Rest Home Modfied March 2021
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 Mailing address(street or P.O.box)
Creekside Manor Rest Home P.O.Box 1487
City or town State ZIP code
o Kernersville NC 27285
U
Contact name(first and last) Title
William Hammonds Owner
t
Phone number Email address
[phone] [e-mail]
o NPDES number of receiving facility(if any) 121 None
a Average daily flow rate 0.005 mgd
E 1.21 Is the wastewater disposed of in a manner other than those already mentioned in Items 1.14 through 1.21 that do
not have outlets to waters of the State of North Carolina(e.g.,underground percolation,underground injection)?
ao
t ❑ Yes ❑ No 4 SKIP to Item 1.23.
O 1.22 Provide information in the table below on these other disposal methods.
Information on Other Disposal Methods
Disposal Location of Size of Annual Average Continuous or Intermittent
Method Disposal Site Disposal Site Daily Discharge (check one)
to Description Volume
acres gpd ❑ Continuous
❑ Intermittent
0
acresgpd ❑ Continuous
❑ Intermittent
acres gpd ❑ Continuous
❑ Intermittent
1.23 Do you intend to request or renew one or more of the variances authorized at 40 CFR 122.21(n)?(Check all that apply.
w Consult with your NPDES permitting authority to determine what information needs to be submitted and when.)
❑ Discharges into marine waters(CWA ❑ Water quality related effluent limitation(CWA Section
er
49 CI Section 301(h)) 302(b)(2))
0 Not applicable
1.24 Are any operational or maintenance aspects(related to wastewater treatment and effluent quality)of the treatment works
the responsibility of a contractor?
❑ Yes ❑ 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
o Contact name(first and
last)
Phone number
Email address
Operational and
maintenance
responsibilities of
contractor
Page 4

NPDES Permit Number Facility Name Modified Application Form 2A
NC0037311 Creekside Manor Rest Home Modified March 2021
SECTION 2.ADDITIONAL INFORMATION(40 CFR 122.21(j)(1)and(2))
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?
01
o ❑ Yes ID No-4 SKIP to Section 3.
0 2.2 Provide the treatment works'current average daily volume of inflow Average Daily Volume of Inflow and Infiltration
and infiltration.
gpd
Indicate the steps the facility is taking to minimize inflow and infiltration.
o
0
c
2.3 Have you attached a topographic map to this application that contains all the required information?(See instructions for
43 0_ specific requirements.)
`as m
o n
❑ Yes ❑ No
E 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.)
o rn
L1 0 ❑ Yes ❑ No
2.5 Are improvements to the facility scheduled?
❑ Yes ❑ No 4 SKIP to Section 3.
= Briefly list and describe the scheduled improvements.
0
1.
E
Q 2.
E
0
3.
w
4.
cn
-o
Ws 2.6 Provide scheduled or actual dates of completion for improvements.
Scheduled or Actual Dates of Completion for Improvements
E Affected Attainment of
Scheduled Begin End Begin
Outfalls Operational
o Improvement Construction Construction Discharge
(from above) (list outfall Level
(MM/DD/YYYY) (MMIDD/YYYY) (lv1M/DD/YYYY)
number) (Mh1/DDIYYYY)
a
1.
_0
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:
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