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Home My WebLink AboutNC0037311_Permit Issuance_20120202NCDENR North Carolina Department of Environment and Natural Resources Division of Water Quality Beverly Eaves Perdue Charles Wakild, P.E. Dee Freeman Governor Director Secretary February 2, 2012 Mr. William R. Hammonds Hammond Properties P.U. Box 485 Kernersville, N.C. 27285-0485 Subject: Issuance of NPDES Permit NCO037311 Creekside Manor Rest Home WWTP Class WW-2 Forsyth County Dear Mr. Hammonds: Division personnel have reviewed and approved your application for renewal of the subject permit. Accordingly, we are forwarding the attached NPDES discharge permit. This permit is issued pursuant to the requirements of North Carolina General Statute 143-215.1 and the Memorandum of Agreement between North Carolina and the U.S. Environmental Protection Agency dated October 15, 2007 (or as subsequently amended). This final permit includes no significant changes from the draft permit sent to you on December 7, 2011. If any parts, measurement frequencies or sampling requirements contained in this permit are unacceptable to you, you have the right to an adjudicatory hearing upon written request within thirty (30) days following receipt of this letter. This request must be in the form of a written petition, conforming to Chapter 150B of the North Carolina General Statutes, and filed with the Office of Administrative Hearings (6714 Mail Service Center, Raleigh, North Carolina 27699-6714). Unless such demand is made, this decision shall be final and binding. Please note that this permit is not transferable except after notice to the Division. The Division may require modification or revocation and reissuance of the permit. This permit does not affect the legal requirements to obtain other permits which may be required by the Division of Water Quality or permits required by the Division of Land Resources, the Coastal Area Management Act or any other Federal or Local governmental permit that may be required. If you have any questions concerning this permit, please contact Charles Weaver at telephone number (919) 807-6391. ' cere y, Z � __'_ lea W.E. cc: Central Files Wilmington Regional Office/Surface Water Protection NPDES Unit i James M. Cheshire / Research & Analytical Laboratories, Inc. [P.O. Box 473, Kernersville, NC 27284.04731 1617 Mail Service Center, Raleigh, North Carolina 27699-1617 One 512 North Salisbury Street, Raleigh, North Carolina 27604 N&Maroaa Phone: 919 807-6300 / FAX 919 807-6495 / hfp://podal.nodenr.orglweblwq //� An Equal Opportunity/AffinnaOveAction Employer -50%Recycled/1Naturally / Permit NCO037311 STATE OF NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES DIVISION OF WATER QUALITY PERMIT TO DISCHARGE WASTEWATER UNDER THE NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM In compliance with the provision of North Carolina General Statute 143-215.1, other lawful standards and regulations promulgated and adopted by the North Carolina Environmental Management Commission, and the Federal Water Pollution Control Act, as amended, the Allegiance Healthcare Investors, LLC is hereby authorized to discharge wastewater from a facility located at the Creekside Manor Rest Home 6206 Reidsville Road Kernersville Forsyth County to receiving waters designated as an unnamed tributary to Belews Creek in subbasin 03-02-01 of the Roanoke River Basin in accordance with effluent limitations, monitoring requirements, and other conditions set forth in Parts I, II, III and IV hereof. This permit shall become effective March 1, 2012. This permit and authorization to discharge shall expire at midnight on February 28, 2017. Signed this day February 2, 2012 FsWakild, P.E., Dire r ision of Water Quality Authority of the Environmental Management Commission Permit NCO037311 SUPPLEMENT TO PERMIT COVER SHEET All previous NPDES Permits issued to this facility, whether for operation or discharge are hereby revoked, and as of this issuance, any previously issued permit bearing this number is no longer effective. Therefore, the exclusive authority to operate and discharge from this facility arises under the permit conditions, requirements, terms, and provisions included herein. Allegiance Healthcare Investors, LLC is hereby authorized to: 1. Continue to operate an existing 0.01 MGD extended aeration wastewater treatment system with the following components: ♦ Bar screen ♦ Aeration basin with diffused air ♦ Secondary clarifier ♦ Tablet chlorination ♦ Chlorine contact basin ♦ Tablet dechlorination ♦ Sludge holding tank The facility is located in Kernersville at Creekside Manor Rest Home off Reidsville Road in Forsyth County. 2. Discharge from said treatment works at the location specified on the attached map into an unnamed tributary to Belews Creek, classified C waters in hydrologic unit 03010103 of the Roanoke River Basin. NCO037311 - Creekside Manor Rest Home Latitude: 36012'49" Sub -Basin: 03-02-01 Longitude: 80°03'49" Hydrologic Unit: 03010103 Quad Name: Belews Creek Stream Class: C Receiving Stream: UT to Belews Creek Facility Location: Yj ��!✓ a ✓VWl4lL Forsyth County [map not to scale] Permit NCO037311 A. (1 ) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS During the period 'beginning on the effective date of this permit and lasting until expiration, the Permittee is authorized to discharge from outfall 001. Such discharges shall be limited and monitored by the Permittee as specified below: PARAMETER `':LIMITS "MONITORING REQUIREMENTS [PCS Cod01 Monthly;Average Daiiy'Maxirr um ', :Measurement Sample Tyke Sample ::. Frequency :.:. Locations. Flow 0.010 MGD Weekly Instantaneous Influent or 50050 Effluent BOD, 5-day (20°C) 30.0 mg/L 45.0 mg/L - Weekly Grab Effluent 00310 Total Suspended Solids 30.0 mg/L 45.0 mg/L Weekly Grab Effluent 00530 NH3 as N (April 1- October 31) 2.0 mg/L 10.0 mg/L Weekly Grab Effluent 00610 NH3 as N (November 1- March 31) 4.0 mg/L 20.0 mg/L Weekly Grab Effluent 00610 Dissolved Oxygen Daily average > 5.0 mg/L Weekly Grab Effluent 00300 Dissolved Oxygen Weekly Grab Upstream & 00300 Downstream Fecal Coliform (geometric mean) 200/100 ml 400/100 ml Weekly Grab Effluent 31616 Total Residual Chlorine (TRC)2 17 pg/L 2Meek Grab Effluent 50060 Temperature (°C) Daily Grab Effluent 00010 Temperature (°C) Weekly Grab Upstream & 00010 Downstream pH > 6.0 and < 9.0 standard units Weekly Grab Effluent 00400 Footnotes: 1. Upstream: approximately 100 feet upstream from the outfall. Downstream: approximately 300 feet downstream from outfall. 2. Limit and monitoring requirements apply ONLY if chlorine is used for disinfection. The Permittee shall report all effluent TRC values reported by a NC -certified laboratory [including field -certified] . Effluent values below 50 dug/ L will be treated as zero for compliance purposes. There shall be no discharge of floating solids or visible foam in other than trace amounts Winston-Salem Journal Advertising Affidavit Account Number Winston-Salem Journal P.O Box 3159 Winston-Salem, NC 27102 NCOENR/DWQ/POINT SOURCE BRANCH ATTN: DINA SPRINKLE 1617 MAIL SERVICE CENTER RALEIGH, NC 27699-1617 �RY[:icitk' Date December 13, 2011 Date Category Description Ad Size Total Cost 12/13/2011 Legal Notices PUBLIC NOTICE North Carolina Environmental Management Commission/NPDES Unit 1617 Mail Service Center Raleigh, NC 27699-1617 Notice of Intent to Issue a NPDES Wastewater Permit The North Carolina Environmental Management Commission proposes to issue a NPDES wastewa- ter discharge permit to the person(s) listed below. Stokes County Schools requested renewal of per- mit . NC0087980/Pine Hall Elementary School WWTP. Facility discharges to Eurins Creek/ Roa- noke River Basin. Currently, fecal coliform is wa- ter quality limited. Stokes County Sciuiols requested renewal of per- mit NC0044962/North Stokes High School WWTP. Facility discharges treated wastewater to anun- named tributary to the Dan River/Roanoke River Basin. Currently total residual chlorine and fecal coliform are water quality limited. Stokes CourRy Schools requested renewal of NPDES perrnif NC0044954/South Stokes High School WWTP. Facility disbharges to Little Neat - man Creek/Roanoke River Basin. Currently, fecal coliform and total residual chlorine are water quality limited. City of Winston-Salem, Forsyth County, has ap- Ved to renew permit NCO086762 for PW SwaTP, m River Ridge Road, discharging filter -back- wash to UT Bashavla Creek, Yadkin River Basin. t Carolina Water Service, Inc. NCrequested renewal of permit NCO06MI for Abington Subdivision WWTP in Forsyth County; this permitted discharge is treated domestic wastewater to Belews Creek, Roanoke River Basin. Horizons Residential Care Center applied for re- newal of NPDES permit NCODS6791 for the Hori- zons Residential Care Center WWTP In Forsyth County; this permitted discharge is treated do- mestic wastewater to Buffalo Creek in the Roa- noke River Basin. Allegiance Healthcare Investors, LLC requested re- newal of permit NC0037311/Creekside Manor Rest Home/Forsyth County. Facility discharges to an unnamed tributary to Belews Creek/Roanoke River Basin. Currently dissolved oxygen, ammonia nitrogen,fecal' coliform and total residual chlorine are water quality limited. PUBLIC NOTICE North Carolina Environmental Managem 1 x 75 L 543.00 Media General Operations, Inc. Publisher of the Winston-Salem Journal Forsyth County Before the undersigned, a Notary Public of Forsyth County, North Carolina, duly commissioned, qualified, and authorized by law to administer oaths, personally appeared S. A. Bragman, who by being duly sworn deposes and says: that she is the Assistant Controller of the Winston-Salem Journal, engaged in the publishing of a newspaper known as Winston-Salem Journal, published, issued and entered as second class mail in the City of Winston-Salem, in said County and State: that she is authorized to make this affidavit and sworn statement: that the notice or other legal advertisement, a true copy of which is attached hereto, was published in the Winston-Salem Journal on the following dates: 12/13/2011 and that the said newspaper in which such notice, paper document, or legal advertisement was published was, at the time of each and every such publication, a newspaper meeting all the requirements and qualifications of Section 1-597 of the General Statutes of North Carolina and was a qualified newspaper within the meaning of Section 1-597 of the General Statutes of North Carolina. This 13th day of December, 2011 (signature of'oson making affidavie) Swom to and subscribed before me, this 13th day My Commission expiresl� 9 THIS IS NOT A BILL. PLEASE PAY FROM INVOICE. THANK YOU RE,: DRAFT permit renewal for NC0037311 / Creekside Manor Rest Home Page 1 of 1 RE: DRAFT permit renewal for NCO037311 / Creekside Manor Rest Home Boone, Ron Sent: Friday, December 02, 2011 7:31 AM To: Weaver, Charles Cc: Basinger, Corey Charles, My only comment is that "tablet dechlorination" should be added to the plant description. That's it! Ron Ron Boone NC DENR Winston-Salem Regional Office Division of Water Quality, Surface Water Protection 585 Waughtown Street Winston-Salem, NC 27107 Voice: (336) 771-4967 FAX: (336) 771-4630 E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties. From: Weaver, Charles Sent: Wednesday, November 30, 2011 10:18 AM To: Boone, Ron; Pugh, James L. Subject: DRAFT permit renewal for NCO037311 / Creekside Manor Rest Home Importance: High This is a class WW-2 permit in Forsyth County. This permit will go to Notice on December 7th. Send me any comments by December 30th Thanks, CHW Messages to and from this address are subject to the NC Public Records Law and may be released to third parties. https://mail.nc.gov/owa/?ae=Item&t=IPM.Note&id=RgAAAADj 9nvla%2bdiSLpH5 CXFs... 12/2/2011 FACT SHEET FOR EXPEDITED PERMIT RENEWALS This form must be completed by Permit Writers for all expedited permits which do not require full Fact Sheets. Expedited permits are generally simple 100% domestics (e.g., schools, mobile home parks, etc) that can be adminishatively renewed with minor changes, but can include facilities with more complex issues (Special Conditions, 303(d) listed water, toxicity testing, instream monitoring, compliance concerns). Basic Information for Expedited Permit Renewals Permit Writer/Date Charles H. Weaver— 11/30/2011 Permit Number NC0037311 Facility Name Creekside Manor Rest Home Basin Name/Sub-basin number Roanoke / 03-02-01 Receiving Stream an unnamed tributan• to Belews Creek Stream Classification in Permit C Does permit need Daily Maximum NH, limits? No — already present Does permit need TRC limits/lan is e? No — already present Does permit have toxicity testing? No Does permit have Special Conditions? No Does permit have mstream monitoring? Yes Is the stream impaired (on 303(d) list)? No Any obvious compliance concerns' No Any permit mods since lastpermit'! Name & ownership change New, expiration date 2/28/2017 Comments received on Draft Permit? Most Commonly Used Expedited Language: • 303(d) laneua¢e for Draft/Final Cover Letters: "Please note that Cane Creek is listed as an impaired waterbody on the North Carolina 303(d) Impaired Waters List. Addressing impaired waters is a high priority with the Division. and instream data will continue to be evaluated. If there is noncompliance with this permit's effluent limits and stream impairment can be attributed to your facility, then mitigative measures may be required". Outfall 001 Great Branch ` (flows northwest)) , Ji \f I it N., 15039 _ UU j(.JT'�ri' �"ice W'-\-..�.�. �'• cJt lll� — ' f - —�— IV NC HWY 903 end Clam Grady Roadl�- ! Bra: y.. Albertson Water & Sewer District Albertsons W&S District WTP USGS Ound/State Grid: Albertson, NC/G27SE Stream Class: C; Swamp Latitude: N 35' 07' 01" Sub -Basin: 03-06-21 Longitude: W 77' 49' 16" HUC: 03030007 Drainage Basin: Cape Fear River Basin Receiving Stream: Great Branch [stream segment 18-74-111 Facility Location not to scale North NPDES Permit NCO063711 Duplin County RESEARCh & ANALyTICA[ LAbORATWES, INC. Analytical/Process Consultations November 10, 2011 Mr. Charles H. Weaver, Jr. NPDES Unit Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 RE: Renewal of NPDES Permit No. NCO037311 Creekside Manor Rest Home W WTP Forsyth County Dear Mr. Weaver, In response to the Notice of Violation dated November 7, 2011 enclosed please find a copy of the Permit Renewal Application that Research & Analytical Laboratories, Inc. (RAL) submitted to NCDENR, Division of Water Quality, on August 29, 2011 by certified mail. Also enclosed is a copy of the certified mail receipt showing that the package was received at your location on August 30, 2011. I trust this will resolve the Notice of Violation, if RAL needs to do anything further or if you should have any additional questions please so advise. Sincerely, P" -'�- �4 . James M. Cheshire President/CEO Enclosure JMC/sy P.O. Box 473. 106 Short Street • Kernersville. North Carolina 27284. 336.996-2841 • Fax 336.996.0326 www.randalabs.com RESEARCh & ANALyTICAI LABORATORIES, INC. Analytical/Process Consultations August 26, 2011 Mr. Charles H. Weaver, Jr. NPDES Unit Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 RE: Renewal of NPDES Permit No. NC0037311 Creekside Manor Rest Home W WTP Forsyth County Dear Mr. Weaver, Please renew NPDES Permit No.NC0037311 for the wastewater treatment plant at Creekside Manor Rest Home. The signed application form in triplicate, a description of the method of sludge disposal and a map of the location of the discharge are all attached. Sincerely, Research & Analytical Labs James M. Cheshire Authorized Agent JMC/sl P.O. Box 473. 106 Short Street • Kernersville, North Carolina 27284.336-996-2841 • Fax 336-996-0326 www.randalabs.com 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 hauled by a licensed septic pumper contractor and disposed of at the City of Greensboro wastewater treatment plant. NPDES APPLICATION - FORM D For privately owned treatment systems treating 100% domestic wastewaters <1.0 MGD Mail the complete application to: N. C. DENR / Division of Water Quality / NPDES Unit 1617 Mail Service Center, Raleigh, NC 27699-1617 NPDES Permit 000037311 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. Box 485 City Kernersville State / Zip Code NC/27285-0485 Telephone Number 336-595-6004 Fax Number 336-595-5999 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 & Analytical Laboratories Mailing Address P.O. Box 473 City Kernersville State / Zip Code NC/27285 Telephone Number (336)996-2841 Fax Number 336-996-0326 1 d 4 Farm-D 05108 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 applyp. Industrial ❑ Number of Employees Commercial ❑ Number of Employees Residential ❑ Number of Homes School ❑ Number of Students/Staff Other ® Explain: Rest Home Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers, restaurants, etc.): Rest Home Population served: S. Type of collection system ® Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer) 6. Outfall Information: Number of separate discharge points 1 Ontfall Identification number(s) 001 Is the outfall equipped with a diffuser? ❑ Yes ® No 7. Name of receiving stream(s) (Provide a map shotving the exact location of each outfaliA. unnamed tributary to Belews Creek S. Frequency of Discharge: ® Continuous ❑ Intermittent If intermittent: Days per week discharge occurs: Duration: 9. Describe the treatment system List all installed components, including capacities, 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 Form-D 05/08 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 0.0063 MGD (for the previous 3 years) MaRimum daily flow 0.0121 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. If more than one analysis is reported, report daily maximum and monthly average. If only one analysis is reported, report as daily maximum. Parameter Daily Maximum Monthly Average Units of Measurement Biochemical Oxygen Demand (BODs) 34.6 12.2 MG/ L Fecal Coliform 580 3.6 Col/ 100 ml Total Suspended Solids 35.0 12.8 MG/L Temperature (Summer) 30.0 25.0 °C Temperature (Winter) 24.0 7.7 °C pH 7.81 7.36 SU 13. List all permits, construction approvals and/or applications: Type Permit Number Type Hazardous Waste (RCRA) UIC (SDWA) NPDES NCO037311 PSD (CAA) Non -attainment program (CAA) 14. APPLICANT CERTIFICATION NESHAPS (CAA) Ocean Dumping (MPRSA) Dredge or fill (Section 404 or CWA) Other 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 of Applicant Date North Carolina General Statute 143-215.6 (b)(2) states: Any person who knowingly makes any false statement representation, 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 knowingly 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, shaft be guilty of a misdemeanor punishable by a fine not to exceed $25,0W, 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 Fomn-D 05108 (Domestic •E CrfC'ML OFFICIAL U7 o m o Peslege $ r Gemnad Fee' O Retum Receipt Fes —1. PmunaA He. O (Endorsement Requi(ed) O Resbieled Delivery Fee O (Endoreemenr Requved) rU rA ru Total Puetego a Fess $ Et lit o St1i rN�a I� cp y V V l-(7 VI . I�•'W��ESQ--L' N orPOB �l IVW`�� •'�- ■ Complete items 1, 2, and 3. Also complete A. Signature Rem 4 If Restricted Delivery Is desired. X ❑ Agent ■ Print your name and address on the reverse ❑ Addressee so that We can return the card to you. ■ Attach this card to the back of the malipiece, B. Received by (Printed Name) C. Date of DelNary or on the front R space permits. 1. Article Addressed to: dernrery addr- d' em t? ❑ Yes N1 \ & S ` I v i y— 1 If YES, enter delivery address bet . ❑ No DiJiSk-by Of � AUG 3 0 2n auali ty llP I -I ►ylai t Ser%fczC CM 12�1 cr9�►� N �- e ceT e Mall S -? � l r j R Retum Receipt for Merchandise �.{,,, �1• A ' C (nG{'� l-cs W-e& ve � ❑ Insured Mall ❑ C.O.D. l' r . 4. Restricted Delivery? (Extra Fee) ❑ Yes 2. Articleffims humsumber 7009 2820 (rrenslerhom servke label) 0001 4030 5485 PS Form 3811. February 2004 Domestic Return Receipt 1025e5n2-1+15e0 NCDENR North Carolina Department of Environment and Natural Division of Water Quality Beverly Eaves Perdue Coleen H. Sullins Governor Director November 4, 2011 Allegiance Healthcare Investors, LLC Attn: William R. Hammonds, Consultant Management P.O. Box 485 Kernersville, NC 27285-0485 COPS( Resources Subject: Compliance Evaluation Inspection Permittee: Allegiance Healthcare Investors, LLC Facility: Creekside Manor Assisted Living Wastewater Treatment Plant NPDES Permit #: NCO037311 Forsyth County Dear Mr. Hammonds: Dee Freeman Secretary Mr. Ron Boone of the Winston-Salem Regional Office of the NC Division of Water Quality (DWQ or the Division) conducted a compliance evaluation inspection (CEI) of the subject facility on November 2, 2011. Clifford Cain's assistance and cooperation during the inspection was greatly appreciated. An inspection checklist is attached for your records and inspection findings are summarized below. General Information The wastewater treatment plant (WWTP) is located at 6206 Reidsville Road in Kernersville, Forsyth County, NC, at approximate coordinates 36.2132370,-80.0644000. The permit authorizes Allegiance Healthcare Investors, LLC, (Allegiance) to operate this 0.01 MGD WWTP, which consists of a bar screen, aeration basin, secondary clarifier, aerobic digester, tablet chlorination, and tablet dechlorination. Allegiance is further authorized to discharge the treated effluent from this WWTP via outfall 001, which is located at approximate coordinates 36.2136110,-80.0636110, into an unnamed tributary to Belews Creek, this section of which is currently classified as Class C waters in the Roanoke River Basin. Site Review The plant itself appears to be in good condition. Everything is currently operational and the plant is meeting effluent limitations the majority of the time. No significant maintenance issues were noted. The mixed liquor in the aeration basin appeared healthy and the settled water in the clarifier looked clear with very few small solids overflowing the weir. There was some floating scum on the clarifier surface and some weir blockage but it was minimal and Mr. Cain stated he normally removes the scum at least three times per week. Mr. Cain is currently using two chlorination tubes and three dechlorination tubes. Mr. Cain is doing a great job operating the plant. Documentation Review All documentation was reviewed. Mr. Cain has done an excellent job producing and keeping the records needed on file. Discharge monitoring reports and field and non -field laboratory records North Camlina Division of Water Quality, Winston-Salem Regional Office Location: 585 Waughtown St. Winston-Salem, North Carolina 27107 Phone: 336-771-50001 FAX: 336-7714630 t Customer Service: 1-877-623-6748 Internet www.ncvvaterquality.org An Equal Opportunity 1 Affinnatve Acton Employer ne NorthCarolina )Vaturally Allegiance Healthcare Investors, LLC Attn: William R. Hammonds, Consultant Management Compliance Evaluation Inspection Creekside Manor Assisted Living W WTP, NCO037311 Page 2 of 2, November 4, 2011 were compared and no discrepancies were found. Mr. Cain uses field discharge monitoring report sheets for his visitation log and an operations log book in which he annotates his daily operational and maintenance activities. The flow for the plant is obtained approximately weekly from the facility's potable water usage meter. Mr. Cain also had complete sludge wasting and removal records on file. Mr. Boone noted no other problems or concerns during his inspection. If you have any questions regarding the inspection or this letter, please call him or me at (336) 771-5000. Thank you for your attention to this matter. Sincerely, 4 W. Corey Basinger Water Quality Regional Supervisor Winston-Salem Region Division of Water Quality Attachments: BIMS Inspection Report CC: WSRO - SWP Central Files NPDES Unit R&A Labs Attn: Cliff Cain 106 Short Street Kernersville, NC 27284 United States Environmental Protection Agency Form Approved. EPA Washington, D.C. 20460 OMB No. 2040-0057 Approval expires 8-31-98 Section A: National Data System Coding (i.e., PCS) Transaction Code NPDES yrlmo/day Inspection Type Inspector Fac Type I I 1 INI 2 1 JS 31 NCO037311 Ill 121 11/11/02 117 181 C I 19II S I 20LJ LJ !� J Remarks 211 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 16 Inspection Work Days Facility Self -Monitoring Evaluation Rating B1 QA ------ -Reserved ------------------- 67 I 169 70 U 71 U 72 U 73 L_U 74 751 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 Entry Time/Date Permit Effective Date POTW name and NPDES permit Number) Creekside Manor Assisted Living 09:00 AM 11/11102 07/11/01 Exit Time/Date Permit Expiration Date 6206 Reidsville Rd Kemersville NC 27284 10:00 AM 11/11/02 12/02/29 Name(s) of Onsite Representative(s)/Titles(s)1Phone and Fax Number(s) Other Facility Data /// Name, Address of Responsible Officialf7litle/Phone and Fax Number Contacted James Cheshire,6206 Reidsville Rd Kerersville NC 27284//336-996-2841/ No Section Q 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 Inspec (s) Agency/Office/Phone and Fax Numbers Date Ron Boone WSRO WQ//336-771-49671 j Signature of nagement Q A Reviewer Agency/Office/Phone and Fax Numbers Date Q --LN1N3 4WZ00 L _X�4�444Ler----- EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete. Page # 1 NPOES yr/mo/day Inspection Type 3) NCO037311 I11 12, 11/11/02 18 _' Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary) Please refer to the attached inspection summary letter. Page # 2 Permit: NCO037311 Owner - Facility: Creekside Manor Assisted Living Inspection Date: 11/02/2011 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 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? ■ ❑ ❑ ❑ Comment: Please refer to the attached inspection summary letter. 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? ■ ❑ ❑ ❑ Are all records maintained for 3 years (lab. reg. required 5 years)? ■ ❑ ❑ ❑ Are analytical results consistent with data reported on DMRs? ■ ❑ ❑ ❑ 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? ■ 000 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 on each shift? ❑ ■ ❑ ❑ Is the ORC visitation log available and current? ■ ❑ ❑ ❑ Is the ORC certified at grade equal to or higher than the facility classification? ■ ❑ ❑ ❑ 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? ■ ❑ ❑ ❑ Facility has copy of previous year's Annual Report on file for review? ❑ ❑ ■ ❑ Comment: Please refer to the attached inspection summary letter. Laboratory Yes No NA NE Are field parameters performed by certified personnel or laboratory? 000 ❑ Page # 3 Permit: NCO037311 Owner - Facility: Creekside Manor Assisted Living Inspection Date: 11/02/2011 Inspection Type: Compliance Evaluation Laboratory Yes No NA NE Are all other parameters(excluding field parameters) performed by a certified lab? ■ ❑ Q 11 # Is the facility using a contract lab? ■ ❑ ❑ 13 # Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees Celsius)? Q Q ❑ ■ Incubator (Fecal Coliform) set to 44.5 degrees Celsius+/- 0.2 degrees? Q ❑ 0 ■ Incubator (BOD) set to 20.0 degrees Celsius +/-1.0 degrees? 0 Q 0 ■ Comment: Please refer to the attached inspection summary letter. Influent Sampling Yes No NA NE # Is composite sampling flow proportional? Q Q ■ 0 Is sample collected above side streams? ■ Q Q Q Is proper volume collected? ■ Q Q 0 Is the tubing clean? ❑ ❑ ■ ❑ # Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees Celsius)? Q Q ❑ ■ Is sampling performed according to the permit? ■ Q Q Q Comment: Please refer to the attached inspection summary letter. Effluent Sampling Yes No NA NE Is composite sampling flow proportional? O Q ■ Q Is sample collected below all treatment units? ■ Q Q 0 Is proper volume collected? ■ 0 Q 0 Is the tubing clean? Q ❑ ■ 0 # Is proper temperature set for sample storage (kept at less than or equal to 6.0 degrees Celsius)? Q ❑ ■ Q Is the facility sampling performed as required by the permit (frequency, sampling type representative)? ■ Q Q Comment: Please refer to the attached inspection summary letter. Upstream / Downstream Sampling Yes No NA NE Is the facility sampling performed as required by the permit (frequency, sampling type, and sampling location)? ■ O ❑ O Comment: Please refer to the attached inspection summary letter. Flow Measurement - Influent Yes No NA NE # Is flow meter used for reporting? ■ ❑ 11 11 Is flow meter calibrated annually? Q Q Q ■ Is the flow meter operational? ■ ❑ 0 0 (If units are separated) Does the chart recorder match the flow meter? ❑ ❑ ■ Q Page # 4 0 Permit: NCO037311 Owner - Facility: Inspection Date: 11/02/2011 Inspection Type: Creekside Manor Assisted Living Compliance Evaluation Flow Measurement - Influent Yes No NA NE Comment: Please refer to the attached inspection summary letter. 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? ■ ❑ ❑ ❑ Is disposal of screening in compliance? ■ 000 Is the unit in good condition? ■ 000 Comment: Please refer to the attached inspection summary letter. 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? ❑ 000 Are the diffusers operational? ■ ❑ ❑ ❑ 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/1) ❑ ❑ ❑ ■ Comment: Please refer to the attached inspection summary letter. 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? ❑ ❑ ■ ❑ Are weirs level? ■ ❑ ❑ ❑ Is the site free of weir blockage? ■ ❑ ❑ ❑ Is the site free of evidence of short-circuiting? ■ ❑ ❑ ❑ Is scum removal adequate? ■ ❑ ❑ ❑ Is the site free of excessive floating sludge? ■ ❑ ❑ Q Is the drive unit operational? ❑ ❑ IN ❑ Page # 5 Permit: NC0037311 Owner - Facility: Creekside Manor Assisted Living Inspection Date: 11/02/2011 Inspection Type: Compliance Evaluation Secondary Clarifier Yes No NA NE Is the return rate acceptable (low turbulence)? ■ ❑ Q Q Is the overflow clear of excessive solids/pin floc? ■ Q ❑ 0 Is the sludge blanket level acceptable? (Approximately % of the sidewall depth) 0000 Comment: Please refer to the attached inspection summary letter. Pumps-RAS WAS Yes No NA NE Are pumps in place? ■ Q Q 0 Are pumps operational? ■ 0 0 0 Are there adequate spare parts and supplies on site? Q ❑ Q ■ Comment: Please refer to the attached inspection summary letter. n_ Vac Nn NO Nr- Type of system ? Tablet Is the feed ratio proportional to chlorine amount (1 to 1)? Q El 11 ■ Is storage appropriate for cylinders? ■ 0 Q Q # Is de -chlorination substance stored away from chlorine containers? ■ ❑ Q ❑ Are the tablets the proper size and type? 0000 Comment: Please refer to the attached inspection summary letter. Are tablet de -chlorinators operational? ■ Q 0 ❑ Number of tubes in use? 3 Comment: Disinfection -Tablet Yes No NA NE Are tablet chlorinators operational? Are the tablets the proper size and type? Number of tubes in use? 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: Please refer to the attached inspection summary letter. Effluent Pipe Is right of way to the outfall properly maintained? Are the receiving water free of foam other than trace amounts and other debris? ■ 00 ❑ ■000 2 QQO■ ■000 Q0❑■ ■000 ■000 Page # 6 Permit: NCO037311 Owner - Facility: Creekside Manor Assisted Living Inspection Date: 11/02/2011 Inspection Type: Compliance Evaluation Effluent Pipe Yes No NA NE If effluent (diffuser pipes are required) are they operating properly? Q O ■ O Comment: Please refer to the attached inspection summary letter. Aerobic Digester Yes No NA NE Is the capacity adequate? 01100 Is the mixing adequate? ■ Q Q Q Is the site free of excessive foaming in the tank? ■ Q ❑ Q # Is the odor acceptable? 000 ❑ # Is tankage available for properly waste sludge? N Q 0 Q Comment: Please refer to the attached inspection summary letter. Operations & Maintenance Yes No NA NE Is the plant generally clean with acceptable housekeeping? ■ ❑ ❑ ❑ Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable Solids, pH, DO, Sludge ■ Q ❑ ❑ Judge, and other that are applicable? Comment: Please refer to the attached inspection summary letter. Page # 7