NC0069370_Renewal (Application)_20200923

ROY COOPER
Governor 7°3 Ir
{
MICHAEL S.REGAN 44, ^",•.
Secretary `
S. DANIEL SMITH NORTH CAROLINA
Director Environmental Quality
September 23, 2020
Brookdale Senior Living DBA Brookdale Hendersonville East
Attn: Andria Dale, Executive Director
2601 Chimney Rock Rd
Hendersonvlle, NC 28792
Subject: Permit Renewal
Application No. NC0069370
Brookdale Hendersonville East
Henderson County
Dear Applicant:
The Water Quality Permitting Section acknowledges the September 16, 2020 receipt of your permit renewal application
and supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW
permitting branch. Per G.S. 150B-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit. The
permit writer will contact you if additional information is required to complete your permit renewal. Please respond in a
timely manner to requests for additional information necessary to allow a complete review of the application and renewal
of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https://deq.nc.gov/permits-regulations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
Sincerely,
Wren Thedford
Administrative Assistant
Water Quality Permitting Section
cc: Central Files w/application
ec: WQPS Laserfiche File w/application
D_E �yi North,:. es Department of Envrcarmentai Queiay I D+v+s,on of Water Resources
Q�'' Asher ;Regora Off oe 12090 U.S.70 Highway I Swannsnoa,North Caro•r.a 28778
828,258-45a0

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 NCOO6 `J 3 7.)
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: L
Owner Name r0o k..A L. ;J,— k V i n. c J.4L•
Facility Name tBr-00 kiLle.. Hu1d e.cSo.. - r? S/L
Mailing Address
2601 C1,inane� Zoc t ?044_4
City }lam L14.4'-s Vet✓; 1 ►`J C_ 074
State / Zip Code
Telephone Number ') 2- r 11
Fax Number (32.1 ) 616_ 3?J 3
e-mail Address
2. Location of facility producing discharge:
Check here if same address as above
Street Address or State Road
City
State / Zip Code
County
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 A) A 12 I C Sv..J c S
Mailing Address £l - P 1 t'q s c,, } C}-
City r_f "12kJ.,
State / Zip Code (\;i, Z >S 7 j
Telephone Number ( !SC3 ) Z 7 '> - L.7 L (
Fax Number ( )
e-mail Address (1/1 a ( C • ;v%
1 of 3 Form-011/12

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 3 3
Residential ❑ Number of Homes
School 0 Number of Students/Staff
Other ❑ Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Number of persons served: I 0'1_
5. Type of collection system
[Sj Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points
Outfall Identification number(s) L,L, 1-
Is the outfall equipped with a diffuser? ❑ Yes 2] No
7. Name of receiving stream(s) (NEW applicants:Provide a map showing the exact location of each
outfall):
8. Frequency of Discharge: 2( Continuous ❑ Intermittent
If intermittent: 11
Days per week discharge occurs: 7 Duration: 7'1 )-t•
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.
i
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2 of 3 Form-D 11/12
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NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow : (.. -5 MGD
Annual Average daily flow r VC-4%( MOD (for the previous 3 years)
Maximum daily flow C. 1-3 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 grub
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 mnrimum.
RENEWAL APPLICANTS: Provide the highest single reading(Daily Maximum)and Monthly Average
over the past 36 months for parameters currently in your permit. Mark other parameters "N/A".
Parameter Daily Monthly Units of
Maximum Average Measurement
Biochemical Oxygen Demand (BOD5) C 7, q j D ; .l
Fecal Coliform ,j i •S Z 3 t
Total Suspended Solids t 5. . 3 t t Yb'.7 1
Temperature (Summer) 2-7 ,3
15c� C
Temperature (Winter) t c C-
pH S,'-+ 7. 3c'r <j�.`
13. List all permits, construction approvals and/or applications:
Type Permit Number Type Permit Number
Hazardous Waste (RCRA) NESHAPS(CAA)
UIC (SDWA) Ocean Dumping(MPRSA)
NPDES Dredge or fill(Section 404 or CWA)
PSD (CAA) Other
Non-attainment program (CAA)
14. APPLICANT CERTIFICATION
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. p/
--kin Dckv.e
e
Printed name of Person Signing Title
DAndiLt. 100C-4 5 / ) E;ii)c
Signature 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, 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 11/12

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow : (-; 23 MGD
Annual Average daily flow + C) 4( MGD (for the previous 3 years)
Maximum daily flow C. •-3 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 currently in your permit. Mark other parameters "N/A".
Parameter Daily Monthly Units of
Maximum Average Measurement
Biochemical Oxygen Demand (BOD5) 5 C • r7 7,2`1 ri 0-13 1
Fecal Coliform rj` i •5 Z 3 -% t vt' ., (
Total Suspended Solids 15. 3 . 31 1 rn7
Temperature (Summer) 21 .3
Temperature (Winter) )-{ t 5-- i.: C-
pH 7. 3c'1 5
13. List all permits, construction approvals and/or applications:
Type Permit Number Type Permit Number
Hazardous Waste (RCRA) NESHAPS(CAA)
UIC (SDWA) Ocean Dumping(MPRSA)
NPDES Dredge or fill(Section 404 or CWA)
PSD(CAA) Other
Non-attainment program (CAA)
14. APPLICANT CERTIFICATION
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.
Wa: >��1 c_LA e •Ir- c- )r
Printed name of Person Signing Title
jArICLU '0 5 / 32E. /,.)(
Signature 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,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-0 11/12