NCG550061_Compliance Evaluation Inspection_20221128 (2)

United States Environmental Protection Agency
E PA Washington, D.C. 20460
Water Compliance Inspection Report
Form Approved.
OMB No. 2040-0057
Approval expires 8-31-98
Section A: National Data System Coding (i.e., PCS)
Transaction Code NPDES yr/mo/day Inspection
1 IN I 2 IL I 3 I NCG550061 111 121 22/11/04 117
Type
1810I
IIIIIIIIIII
Inspector Fac Type
19I S I 2011
21IIIIII IIIIIIIIIII IIIIIII I IIIIII
P6
Inspection Work Days Facility Self -Monitoring Evaluation Rating B1 QA Reserved
671 I 70I I 711 172 I N I 73I 1 74 71
I I
I I I I I I 180
Section B: Facility Data
Name and Location of Facility Inspected (For Industrial Users discharging to POTW, also include
POTW name and NPDES oermit Number)
120 Roswell Drive
120 Roswell Dr
Kernersville NC 27284
Entry Time/Date
11:30AM 22/11/04
Permit Effective Date
20/11/20
Exit Time/Date
12:30PM 22/11/04
Permit Expiration Date
25/10/31
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
///
Other Facility Data
Name, Address of Responsible Official/Title/Phone and Fax Number
Contacted
Sam M Bradley,120 Roswell Dr Kernersville NC 27284//336-996-2753/3369967148
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit
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
Gary Hudson DWR/Division of Water Quality/336-776-9694/
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
Docusigned by: 11/21/2022
IL— T. Stiacr
EPA`Ferrh45351617-23c(Rgp6 9-94) Previous editions are obsolete.
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sI
NPDES yr/mo/day
N CG550061 111 121 22/11/04
117
Inspection Type
18 [j
1
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
*The single-family subsurface sand filter appeared to be very well maintained.
*The septic tank is pumped and inspected every three to five years.
*The effluent pipe was not located during the inspection.
*The septic tank is pumped and inspected every three to five years.
*Ms. Bradley adds chlorine tablets every month.
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Permit: NCG550061
Inspection Date: 11/04/2022
Owner - Facility: 120 Roswell Drive
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 El El ❑
application?
Is the facility as described in the permit? • El El El
# Are there any special conditions for the permit? El El • El
Is access to the plant site restricted to the general public? ❑ ❑ • ❑
Is the inspector granted access to all areas for inspection? • El El El
Comment:
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