NCG550092_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
1 IN
Code
I 2
IL
NPDES yr/mo/day Inspection Type Inspector Fac
I 3 I NCG550092 111 121 22/11/03 117 181OI 19I S I 2011
Type
21I
I
I I
I
I I
I
I
I
I
I I I I I I
I I I
I
I
I
I
I
I I
I I
I I I
I
I
I I
I I I I 1 I
P6
Inspection
671
Work Days
Facility Self -Monitoring
I 70I
Evaluation Rating
I 711
B1
1
72
QA
I N I
73I
I
I I
Reserved
74 71
1
1 1
1
1
1
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)
5959 Holder Road
5959 Holder Rd
Clemmons NC 27012
Entry Time/Date
10:OOAM 22/11/03
Permit Effective Date
21/08/05
Exit Time/Date
10:30AM 22/11/03
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
Rhonda Baxley,5959 Holder Rd Clemmons NC 27012//757-879-3344/
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
FL—o, T. SA,�dcr
145B49E225C94EA...
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
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31
NPDES yr/mo/day
N CG550092 111 121 22/11/03
117
Inspection Type
18 [j
1
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
*Ms. Baxley recently bought the home, and it is currently vacant and being renovated.
*The septic tank is pumped and inspected every three to five years.
*The chlorinator was not located during the inspection.
*The effluent pipe was not located during the inspection.
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Permit: NCG550092
Inspection Date: 11/03/2022
Owner - Facility: 5959 Holder Road
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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