NCG550074_Compliance Evaluation Inspection_20200130 (2)

United States Environmental Protection Agency
Form Approved.
EPA Washington, D.C. 20460
OMB No. 2040-0057
Water Compliance Inspection Report
Approval expires 8-31-98
Section A: National Data System Coding (i.e., PCS)
Transaction Code NPDES yr/mo/day Inspection Type Inspector Fac Type
1 IN I 2 15 I 3 I NCG550074 111 12 I 20/01/30 I17 18 I S J 19 L G] 201 I
211111 1 1 I I I I II I I I I I I I I I I I I 1 I I I I I I I I I I II I I I I I f6
Inspection
Work Days Facility Self -Monitoring Evaluation Rating 131 QA ---------------------- Reserved -------------------
671
70 I I 71 I I 72 I r I 73 I I 174 751 I I I I I I I80
u ty I I i
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 oermit Number)
11:00AM 20/01/30
18/10/29
2765 Hope Church Road
2765 Hope Church Rd
Exit Time/Date
Permit Expiration Date
Winston Salem NC 27127
11:30AM 20/01/30
20/10/31
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
Elvin T Kinslow,2765 Hope Church Rd Winston Salem NC 27127M
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit 0 Records/Reports 0 Facility Site Review 0 Effluent/Receiving Waters
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 Docusigned by: Agency/Office/Phone and Fax Numbers Date
Lon Snider Luti 'i 'Sider 2/24/2020
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
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NPDES yr/mo/day Inspection Type
NCG550074 I11 121 20/01/30 117 18 JCJ
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
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Permit: NCG550074 Owner - Facility: 2765 Hope Church Road
Inspection Date: 01/30/2020 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
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0
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application?
Is the facility as described in the permit?
0
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# Are there any special conditions for the permit?
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0
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Is access to the plant site restricted to the general public?
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0
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Is the inspector granted access to all areas for inspection?
0
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Comment:
Record Keeping
Yes No NA NE
Are records kept and maintained as required by the permit?
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0
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Is all required information readily available, complete and current?
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0
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Are all records maintained for 3 years (lab. reg. required 5 years)?
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0
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Are analytical results consistent with data reported on DMRs?
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0
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Is the chain -of -custody complete?
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0
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Dates, times and location of sampling
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Name of individual performing the sampling
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Results of analysis and calibration
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Dates of analysis
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Name of person performing analyses
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Transported CM
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Are DMRs complete: do they include all permit parameters?
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Has the facility submitted its annual compliance report to users and DWQ?
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(If the facility is = or > 5 MGD permitted flow) Do they operate 24/7 with a certified operator
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on each shift?
Is the ORC visitation log available and current?
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0
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Is the ORC certified at grade equal to or higher than the facility classification?
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0
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Is the backup operator certified at one grade less or greater than the facility classification?
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0
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Is a copy of the current NPDES permit available on site?
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0
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Facility has copy of previous year's Annual Report on file for review?
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0
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Comment:
Effluent Pipe Yes No NA NE
Is right of way to the outfall properly maintained? ❑ ❑ 0 ❑
Are the receiving water free of foam other than trace amounts and other debris? ❑ ❑ 0 ❑
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Permit: NCG550074
Inspection Date: 01/30/2020
Effluent Pipe
If effluent (diffuser pipes are required) are they operating properly?
Comment:
Owner - Facility: 2765 Hope Church Road
Inspection Type: Compliance Evaluation
Yes No NA NE
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