NC0035157_Renewal (Application)_20190621

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
Mail the complete application to: -_ F-MAPI ED
N. C. DENR / Division of Water Quality / NPDES Unit
1617 Mail Service Center, Raleigh, NC 27699-1617ry�,f,�
NPDES Permit NCO035157 u W
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
McDowell County Adult Care, LLC.
Facility Name
Cedarbrook Residential Center
Mailing Address
PO Box 1257
City
Marion
State / Zip Code
NC / 28752
Telephone Number
[phone]
Fax Number
( )
e-mail Address
2. Location of facility producing discharge:
Check here if same address as above ❑
Street Address or State Road 1267 Pinnacle Church Road
City Nebo
State / Zip Code NC / 28761
County McDowell
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 KALE Environmental, Inc.
Mailing Address 2905 Wood Road
City Mooresboro
State / Zip Code NC / 28114
Telephone Number (828) 657 -1810
Fax Number [phone]
e-mail Address [e-mail]
1 of 3 Form-D 11112

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 apply:
Industrial
❑
Number of Employees
Commercial
®
Number of Employees to Per shift
Residential
❑
Number of Homes
School
❑
Number of Students/Staff
Other
❑
Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Nursing Home - domestic only
Number of persons served: 8
5. Type of collection system
® Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
G. Outfall Information:
Number of separate discharge points 1
Outfall Identification numbers) 001
Is the outfall equipped with a diffuser? ❑ Yes ® No
7. Name of receiving stream(s) (NEW applicants: Protfide a map shouring the exact location of each
outfallj
South Muddy Creek
8. 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 prouided is not sufficient, attach the description of the treatment system in a
separate sheet of paper.
Plant is designed for 3,000 galloons per day at 85% removal. Plant components are:
3,000 gallon septic tank, 2,000 gallon grey water tank, 1,000 dosing tank, single pass
sand filter bed, table chlorinator, chlorine contact chamber, and a table de -chlorination
system.
2 of 3 Farm-D 11112

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow 0.003 MGD
Annual Average daily flow 0.0016 MGD (for the previous 3 years)
Maximum daily flow 0.003 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes ® No
12. Effluent Data
NEW APPLICANTS: 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.
RENEWAL APPLICANTS: Provide the highest single reading (Daily Maximum) and Monthly Average over
the past 36 months for parameters currentlu in uour nerm.it._ Mark other nnramvtvrc "N/A"
Parameter
Daily
Maximum
Monthly
Average
Units of
Measurement
Biochemical Oxygen Demand (BODs)
47.35
52.5
mg/l
Fecal Coliform
83.9047
300
#/ 100ml
Total Suspended Solids
14.5
21.3
mg/l
Temperature (Summer)
24.74
25.2
C
Temperature (Winter)
19.66
20.6
C
pH
7.1
7.2
Standard Units
13. List all permits, construction approvals and/or applications:
Type Permit Number Type
Hazardous Waste (RCRA)
U1C (SDWA)
NPDES
PSD (CAA)
Non. -attainment program (CAA)
NCO035157
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.
Rachael G. Kramer Authorized Re resentative
Pri,plrftame of Person -big ing Title
of
Date
Ncfrth Carolina Gek-d Statute 143-215.6 (b)(2) states: Any person who knowingYmakes 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, shall be
guilty of a misdemeanor punishable by a fine not to exceed $25,000, 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.)
3 of 3 Form-D 11i12