NC0045012_Regional Office Historical File Pre 2018

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NCDENR.
North Carolina Department of Environment and Natural Resources
Division of.Water Quality
Beverly Eaves Perdue, Governor Coleen H: Sullins, Director~ Dee Freem n�Scre
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March 10, 2009 . MAR 1 6 2009
Ms. Pamela E. Ford
Hill Haven Residential Care
224 Augusta Drive .
Statesville, N.C. 28625
Subject: Issuance of NPDES Permit NCO045012
Hill Haven Residential Care WWTP
Iredell County
Dear Ms. Ford:
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 major changes from the draft permit sent to you
on January 14, 2009. Your WWTP shall not discharge any wastewater until the
Facility Certification required in Part A. (2) has been received and approved by the
Division.
We remind you, that Third Creek is listed as an impaired stream on North'Carohna's 303(d)
list. This means that the stream does not meet all water quality standards. The Division is
working toward the improvement of water quality in Third Creek. If the current changes to
permits discharging to Third Creek do not result in improved water quality, removal of
discharges to Third Creek may be necessary for the health of the stream.
Although the Division believes non -point sources [including agricultural runoff] are the main
cause of degradation to Third Creek, we will continue to monitor compliance at your facility. If
noncompliance with your permit's effluent limits is shown to be a direct cause of stream
degradation, the Divisionmill recommend removal of your facility's discharge.
Part III of your permit requires you to "continually evaluate all wastewater disposal
alternatives and pursue the most environmentally sound alternative of the reasonably cost
effective alternatives'.' to surface water discharge.. Such an evaluation may help you find an
alternative to surface water discharge that is more appropriate for your facility.
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 One 7
512 North Salisbury Street, Raleigh, North Carolina 27604 North Carohna
Phone: [phone] FAX [phone] I Internet: www.ncwaterquality.org Natunally
An Equal Opportunity/Affirmative Action Employer — 50% Recycledl10% Post Consumer Paper

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 Actor 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
[phone].
S' cerely,
U V
oleen H. Sullins
cc: Central Files_
19IMS-
sville Regional-Office/Surface Water Protection
Unntt

Permit.N00045012
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
PERMIT
TO DISCHARGE WASTEWATER UNDER THE
NATIONAL POLLUTANT DISCHARGE ELINIINATION 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,
Hill Haven Residential Care, Inc.
is hereby authorized to discharge wastewater from a facility located at the
Hill Haven Residential Care
224 Augusta Drive,
Statesville
Iredell County
to receiving waters designated as an unnamed tributary to Third Creek in subbasin 03-07-
06 of the Yadkin -Pee Dee River Basin in accordance. with effluent limitations, monitoring
requirements, and other conditions set forth in Parts I, II, III, and IV hereof.
The permit shall become effective April 1, 2009. -
This permit and the authorization to discharge shall expire at midnight on March 31, 2014.
Signed this day March 10, 2009
C een H. Sullins, Director
Division of Water Quality
By Authority -.of the Environmental Management Commission

t
Permit NCO045012
SUPPLEMENT TO PERMIT COVER SHEET
All previous NPDES Permits issued to this facility, whether for operation or discharge are hereby revoked. As of this
permit 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.
_ Hill Haven Residential Care, Inc. is hereby authorized to:
0
1.. Continue to operate an existing 0.018 MGD wastewater treatment plant
consisting of the following components:
• Two septic tanks
• Two surface sand filters
• Effluent chlorination
The facility is located at Hill Haven Residential Care [224 Augusta Drive,
-Statesville] in Iredell County.
2. Discharge from said treatment works at the location specified on the attached
map into an unnamed tributary to Third Creek, currently classified C waters in
subbasin 03-07-06 of the Yadkin -Pee Dee River Basin.

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Hill Haven Residential Care - NCO045012 Facility
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Location
USGS Quad Name: Troutman Lat.: 35°44'45"ti-
Receiving Stream: UT to Third Creek Long.: 80053'44" f
Stream Class: C
i
Subbasin: 03-07-06 Not to SCALE

Permit NCO045012
A. (1) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS
During the period beginning after receipt of the Facility Certification described in A. (2) 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
Monthly
Daily '`
Measuremenf
Sample;
Sample
Avera a
Maximum
-` Fre eni
T e `' •
Location
Flow
0.018 MGD .
Weekly
Instantaneous
Effluent
BOD, 5 day, 20 °C _
30.0 mg/L
45.0 mg/L
2/1VIonth
Grab
Effluent
Total Suspended Solids
30*0 mg/L
45.0 mg/L
2/Month
Grab
Effluent
NH3 as N
9.4 tng/L
35.0 mg/L
2/Month
Grab
Effluent
(April 1 to October 31
NH3 as N
30.0 mg/L
35.0 mg/L
2/Month
Grab
Effluent
November 1 to March 31
Fecal Coliform
200/100 mL
400/100 mL
2/Month
Grab
Effluent
(geometric mean
Total Residual Chlorine
28 Ng/L
2Meek
Grab
Effluent
TRC l
Temperature
Weekly
Grab
Effluent
Total Nitrogen
Quarterly
Grab
Effluent
NO2 + NO3 + TKN
Total Phosphorus
Quarterly
Grab
Effluent
pH
> 6.0 and < 9.0 standard units
2/Month
Grab
Effluent •
Notes:
1. TRC limit and monitoring. requirements apply ONLY if chlorine is used for disinfection. The facility
shall report all effluent TRC values reported by a NC certified.laboratory including field certified.
However, effluent values below 50 µg/L will be treated as zero for compliance purposes.
There shall be no discharge of floating solids or foam visible in other than trace amounts.
A. (2) FACILITY CERTIFICATION REQUIREMENT
Due to -the decline of the WWTP since the facility ceased 'discharging, all existing components.
must be certified as operational prior to any future wastewater discharge.
➢ A Professional Engineer licensed in North Carolina . must inspect and certify all facility
components. The record- of the inspection and certification shall be provided to the NC
DENR Mooresville Regional Office (MRO) and the NPDES program.
➢ The MRO must review and approve the Facility Certification in writing prior to any future
wastewater discharge.
Send the Facility Certification to:
NC DENR / DWQ / NPDES
Western Program Supervisor and
1617 Mail Service Center
Raleigh, NC 27699-1617
Surface Water Protection
NC DENR / Mooresville Regional Office
919 North Main Street
Mooresville, NC 28115 .

NPDES Permit Standard Conditions
Page 1 of 16
PART II
STANDARD CONDITIONS FOR NPDES PERMITS
Section A. Definitions
2/Month
Samples are collected twice per month with at least ten calendar days between sampling. events.
3/Week
Samples are collected three times per week on three separate calendar days.
Act or "the Act".
The Federal Water Pollution Control Act, also known as the Clean Water Act, as amended, 33 USC 1251, et. seq.
Annual Average,
The arithmetic mean of all "daily discharges" of a pollutant measured during the calendar year. In the case of fecal
coliform, the geometric mean of such discharges.
Arithmetic Mean
The summation of the individual values divided by the number of individual values.
B ass
The known diversion of waste streams from any portion of a treatment facility including the collection system, which
is not a designed or established or operating mode for the facility.
Calendar Day
The period from midnight of, one day until midnight of the next day. However, for purposes of this permit, any
consecutive 24-hour period that reasonably represents the calendar day may be used for sampling.
Calendar Quarter
One of the following distinct periods: January through March, April through June, July _ through September, and
October through December.
Composite Sample
A sample collected over a 24-hour period by continuous sampling or combining grab samples of at least 100 ml in
such a manner as to result in a total sample representative of the wastewater discharge during the sample period. The
Director may. designate the most appropriate method (specific number and size of. aliquots necessary, the time
interval between grab samples, etc.) on a case -by -case basis. Samplesmay be collected manually or automatically.
Composite samples may be obtained by the following methods:
(1) Continuous: a single, continuous sample collected over a 24-hour period proportional to the rate of flow.
(2) Constant time/variable ' volume: a series of grab samples collected at equal time intervals over a 24 hour
period of discharge and combined proportional to the rate of flow measured at the time, of individual sample
collection, or
(3) Variable .time/constant volume: a series of grab samples of equal volume collected over a 24 hour period
with the' time intervals between samples determined by a preset number of gallons passing the sampling
point. Flow measurement between sample intervals shall be determined by use of a flow recorder and
totalizer, and the preset gallon interval between'sample collection fixed at no greater than 1/24 of the
expected total daily flow at the treatment system, or
(4) Constant'time/constant volume: a series of grab samples of equal volume collected over a'24-hour period at
a constant time interval. Use of this method requires prior approval by the Director. This method
may only be used in situations where effluent flow rates vary less than 15 percent. The following
restrictions also apply:
➢ Influent and effluent grab samples shall be of equal size and of no less than 100 milliliters
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NPDES Permit Standard Conditions
Page 2 of 16
➢ Influent samples shall not be collected more than once per hour.
➢ Permittees with wastewater treatment systems whose detention time < 24 hours shall collect effluent
grab samples at intervals of no greater than 20 minutes apart during any 24-hour period.
➢ Permittees with wastewater treatment systems whose detention time exceeds 24 hours shall collect
effluent grab samples at least every X hours [X = days detention time] over a 24-hour period. Effluent
samples shall be collected at least every six hours; there must be a minimum of four samples during a 24-
hour sampling period.
Continuous flow measurement
Flow monitoring that occurs without interruption throughout the operating hours of the facility. Flow shall be
monitored continually except for the infrequent times when there may be no flow or for infrequent maintenance
activities on the flow device.
Daily Discharge
The discharge of a pollutant measured during a calendar day or any 24-hour period that reasonably represents the
calendar day for purposes of sampling. For pollutants measured in units of mass, the "daily discharge" is calculated as
the total mass of the pollutant discharged over the day. The "daily discharge" concentration comprises the mean
concentration for a 24-hour sampling period as either a composite sample concentration or the arithmetic mean of all
grab samples collected during that period. (40 CFR 122.2)
Daily Maximum
The highest "daily discharge" for conventional and other non -toxicant parameters. NOTE: Permittees may not
submit a "daily average" calculation [for determining compliance with permit limits] for toxicants. See the relevant
Federal effluent guideline[s] for the appropriate calculation interval.
Daily Sampling
Parameters requiring daily sampling shall be sampled 5 out of every 7 days per week unless otherwise specified in the
permit. The Division expects that sampling shall be conducted on weekdays except where holidays or other
disruptions of normal operations prevent weekday sampling. If sampling is required for all seven days of the week
for any permit parameter(s), that requirement will be so noted on the Effluent Limitations and Monitoring Page(s).
DM or "the Division"
The Division of Water Quality, Department of Environment and Natural Resources.
EMC
The North Carolina Environmental Management Commission.
Facility Closure
The cessation of wastewater treatment it a permitted facility, or the cessation of all activities that require coverage
.under the NPDES. Completion of facility closure will allow this permit to be rescinded.
Geometric Mean
The Nth toot of the product of the individual values where N = the number of individual values. For purposes of
calculating the geometric mean, values of "0" (or "< [detection level]") shall be considered = 1.
Grab Sample
Individual samples of at least 100 ml collected over a period of time not exceeding 15 minutes. Grab samples can be
collected manually. Grab samples must be representative of the discharge (or the receiving stream, for instream
samples).
Hazardous Substance
Any substance designated under 40 CFR Part 116 pursuant to Section 311 of the Clean Water Act.
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NPDES Permit Standard Conditions
Page 3 of 16
Instantaneous flow measurement.
A measure of flow taken at the time of sampling; when both the sample `and flow will be representative of the total
discharge.
Monthly Average (concentration Emit)
The arithmetic mean of all "daily discharges" of a pollutant measured during the calendar month. In the case of fecal
coliform, the geometric mean of such discharges.
Permit Issuing Authority
The Director of the Division of Water Quality.
Quarterly Average (concentration limit
The average of all samples taken over a calendar quarter.
Severe property damage
Substantial physical damage to property, damage to the treatment facilities which causes them to become inoperable,
or substantial and permanent loss of natural resources which can reasonably be expected to occur in the absence of a
bypass. Severe,property damage excludes economic loss caused by delays in production.
Toxic Pollutant:
Any pollutant listed as toxic under Section 307(a)(1) of the Clean Water Act.
U set
An incident beyond the reasonable control of the Permittee causing unintentional and temporary noncompliance with
permit effluent limitations and/or monitoring requirements. An upset does not include noncompliance caused by
operational error; improperly designed treatment . facilities, inadequate treatment facilities, lack of preventive
maintenance, or careless or improper operation.
Weekly Average (concentration limi)
The arithmetic mean of,all "daily discharges" of a pollutant measured during the calendar week. In the case of fecal
coliformi, the geometric mean of such discharges.
Section B. General Conditions
1. Duty to Comply
The Permittee must comply with all conditions of this permit. Any permit noncompliance constitutes a violation
of the Clean Water Act and is grounds for enforcement action; for permit termination, revocation and reissuance,
or modification; or denial of a permit renewal application [40 CFR 122.41].
a. The Permittee shall comply .with effluent standards or prohibitions established under section 307(a) of the
Clean Water Act for toxic pollutants acid with standards for sewage sludge use or disposal established under
section- 405(d) .of the Clean Water Act within the time provided in the regulations that establish these
standards or prohibitions or standards for sewage sludge use or disposal, even if the permit has not yet been
modified to incorporate the requirement.
b. The Clean Water Act provides that any person who violates section 301, 302, 306, 307, 308, 318 or 405 of the
Act, or any permit condition or limitation implementing any such sections in a permit issued under section
j 402, or any requirement imposed in a pretreatment program approved under sections 402(a)(3) or 402(b)(8)
of the Act, is subject to ' a civil penalty not to exceed $25,000 per day for each violation. [40 CFR 122.41 (a)
I (2)]
c.' The Clean Water Act provides that any person who negligently violates sections 301, 302, 306, 307, 308, 318, or
405 of the Act, or any condition or limitation implementing any of such sections in a permit issued under
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NPDES Permit Standard Conditions
Page 4 of 16
section 402 of the Act, or any requirement imposed in a pretreatment program approved under section
402(a)(3) or 402(b)(8) of the Act, is subject to criminal penalties of $2,500 to $25,000. per day of violation, or
imprisonment of not more than 1 year, or both. In the case of a second or subsequent conviction for a
negligent violation, a person shall be subject to criminal penalties of not more than $50,000 per day of
violation, or by imprisonment of not more than 2 years, or both. [40 CFR 122.41 (a) (2)]
d. Any person who knoningl
y violates such sections, or such conditions or limitations is subject to criminal
penalties of $5,000 to $50,000 per day of violation, or imprisonment for not more than 3 years, or both. In
the case of a second or subsequent conviction for a- knowing violation, a person shall be subject to criminal
penalties of not more than $100,000 per day of violation, or imprisonment of not more than 6 years, or both.
[40 CFR 122.41 (a) (2)]
e. Any person who knowingly violates section 301, 302, 303, 306, 307, 308, 318 or 405 of the Act, or any permit
condition or limitation implementing any of such sections in a permit issued under section 402 of the Act,
and who knows at that time that he thereby places another person in imminent danger of death or serious
bodily injury, shall, upon conviction, be subject to a fine of'not more than $250,000 or imprisonment of not
more than 15 years, .or both. In the case of a second or subsequent conviction for a knowing endangerment
violation, a person shall be subject to a fine of not more than $500,000 or by imprisonment of not more than
30 years, or both. An organization, as defined in section 309(c)(3)(B)(iii) of the CWA, shall, upon conviction
of violating the imminent danger provision, be subject to a fine of not more than $1,000,000 and can be fined
up to $2,000,000 for second or subsequent convictions. [40 CFR 122.41 (a) (2)]
f. Under state law, a civil penalty of not more than $25,000 per violation may be assessed against any person
who violates or fails to act in accordance with the terms, conditions, or requirements of a permit. [North
Carolina General Statutes 5' 143-215.6A]
g. Any person may be assessed an administrative penalty by the Administrator for violating section 301, 302,
306, 307, 308, 318 or 405 of this Act, or any permit condition or limitation implementing any of such
sections in a permit issued under section 402 of this Act. Administrative penalties for Class I violations are
not to exceed $10,000 per violation, with the maximum amount of any Class I penalty assessed not to exceed
$25,000. Penalties for Class II violations are not to exceed $10,000 per day for each day during which the
violation continues, with the maximum amount of any Class II penalty not to exceed $125,000. [40 CFR
122.41 (a) (3)]
2. Duty to Mitigate 4
The Permittee shall take all reasonable steps to minimize or. prevent any discharge or sludge use or disposal in
violation of this permit with a reasonable likelihood of adversely affecting human health or the environment [40
CFR 122.41 (d)].
3. Civil and Criminal Liability
Except as provided in permit conditions on "Bypassing" (Part II. C. 4), "Upsets" (Part II. C. 5) and "Power
Failures" (Part II. C. 7), nothing in this permit shall be construed to relieve the Permittee from any
responsibilities, liabilities, or penalties for noncompliance pursuant to NCGS 143-215.3, 143-215.6 or Section 309
of the Federal Act, 33 USC 1319. Furthermore, the Permittee is responsible for consequential damages, such as
fish kills, even though the responsibility for effective compliance may be temporarily suspended.
4. Oil and Hazardous Substance Liability
Nothing in this permit shall be construed to preclude the institution of any legal action or relieve the Permittee
from any responsibilities, liabilities, or penalties to which the Permittee is or may be subject to under NCGS 143-
215.75 et seq. or Section 311 of the Federal Act, 33 USG 1321. Furthermore, the Permittee is responsible for
consequential damages, such as fish kills, even though the responsibility for effective compliance may be
temporarily suspended.
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NPDES Permit Standard Conditions
Page 5.of 16
5. PropertyRights
The issuance of this permit does not convey any property rights in either real or personal property, or any
exclusive privileges, nor does it authorize any injury to private property or any invasion of personal rights, not
any infringement of Federal, State or local laws or regulations [40 CFR 122.41 (g)].
6. Onshore or Offshore Construction
This permit does not authorize or approve the construction of any onshore or offshore physical structures or
facilities or the undertaking of any work!in any navigable waters.
7. Severability
The provisions of this permit are severable. If any provision of this permit, or the application of any provision of
this permit to any circumstances, is held invalid, the application of such provision to other circumstances, and the
remainder of this permit, shall not be affected thereby [NCGS 150B-23].
8. Duty to Provide Information
The Permittee shall, furnish to the Permit Issuing Authority, within a reasonable time, any information which the
Permit Issuing Authority may request to determine whether cause exists for modifying, revoking and reissuing, or
terminating this permit or to determine compliance with this permit. The Permittee shall also furnish to the
Permit Issuing Authority upon request, copies of records required by this permit [40 CFR 122.41 (h)].
9. Duty to Reapply
If the Permittee wishes to continue an activity regulated by this permit after the expiration date of this permit, the
Permittee must apply for and obtain a new permit [40 CFR 122.41 (b)].
10. Expiration of Permit
The Permittee is not authorized to discharge after the expiration date. In order -to receive automatic
authorization to discharge beyond the expiration date, the Permittee.shall submit such information, forms, and
fees as are required by the agency authorized to issue permits no later than 180 days prior, to the expiration date.
Any Permittee that has not requested renewal at least 180 days prior to expiration, or any Permittee that does not
have a permit after the expiration and has not requested renewal at least 180 days prior to expiration, will subject
the Permittee to enforcement procedures as provided in NCGS 143-215.6 and 33 USC 1251 et. seq.
11. S' atory Requirements
All applications, reports, or information submitted to the Permit Issuing Authority shall be signed and certified
[40 CFR 122.41 (k)].
a. All permit applications shall be signed as follows:
(1) For a corporation: by a responsible corporate officer. For the purpose of this Section, a responsible
corporate officer means: (a) a 'president, secretary, treasurer or vice president of the corporation in
charge of a principal business function, or any other person who performs similar policy or decision
making functions for the corporation, or (b) ,the manager of one or more manufacturing; production, or
operating facilities, provided, the manager is authorized to make management decisions which govern the
operation of the regulated facility including having the explicit or implicit duty of making major capital
investment recommendations, and initiating and directing other comprehensive measures to assure long
term environmental compliance with environmental laws and regulations; the manager can ensure that
the necessary systems are established or actions taken to gather complete and accurate information for
permit application requirements; and where authority to sign documents has been assigned or delegated
to the manager in accordance with corporate.procedures .
(2) For a partnership or sole proprietorship: by a general partner or the proprietor, respectively; or
(3) For a municipality, State, Federal, or, other public agency: by either a principal executive officer or
ranking elected official [40 CFR 122.22].
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b. All reports required by the permit and other information requested by the Permit Issuing Authority shall be
signed by a person described in paragraph a. above or by a duly authorized representative of that person. A
person is a duly authorized representative only if:
1. The authorization is. made in writing by a person described above;
2. The authorization specified either an individual or a position having responsibility for the overall
operation of the regulated facility or activity, such as the position of plant manager, operator of a well or
well field, superintendent, a position of equivalent responsibility, or an individual or position having
overallresponsibility for environmental matters for the company. (A duly authorized representative may
thus be either a named individual or any individual occupying a named position.); and
3. The written authorization is submitted to the Permit Issuing Authority [40 CFR 122.22]
c. Changes to authorization: If an authorization under paragraph (b) of this section is no longer accurate
because a different individual or position has responsibility for the overall operation of the facility, a new
authorization satisfying the requirements of paragraph (b) of this section must be submitted to the Director
prior to or together with any reports, information, or applications to be signed by an authorized
representative [40 CFR 122.22]
d. Certification. Any person signing a document under paragraphs a. or b. of this section shall make the
following certification [40 CFR 122.22]:
"I certify, under penalty of law, that this document and all attachments were prepared under 'my direction or
supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate
the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including the possibility of fines and imprisonment for knowing violations. "
12. Permit Actions
This permit may be modified, revoked and reissued, or terminated for cause. The filing of a request by the
Permittee for a permit modification, revocation and reissuance, or termination, or a notification of planned
changes or anticipated noncompliance does not stay any permit condition [40 CFR 122.41 (Q.
13. Permit Modification, Revocation and Reissuance, or Termination
The issuance of this permit does not prohibit the permit issuing authority from reopening and modifying the
permit, revoking and reissuing the permit, or terminating the permit as allowed by the laws, rules, and regulations
contained in Title 40, Code of Federal Regulations, Parts 122 and 123; Tide 15A of the North Carolina
Administrative Code, Subchapter 2H .0100; and Nordi Carolina General Statute 143-215.1 et. al.
14. Annual Administering and Compliance Monitoring Fee Requirements
The Permittee must pay the annual administering and compliance monitoring fee within thirty days after being
billed by the Division. Failure to pay the fee in a timely manner in accordance with 15A NCAC 2H.0105 (b) (2)
may cause this Division to initiate action to revoke die permit.
Section C. Operation and Maintenance of Pollution Controls
Certified Operator
Upon classification of the permitted facility by the Certification Commission, the Permittee shall employ a
certified water pollution control treatment system operator in responsible charge (ORC) of the water pollution
control treatment system. Such operator must hold a certification of the grade equivalent to or greater than the
classification assigned to the water pollution control treatment system by the Certification Commission. The
Permittee must also employ one or more certified Back-up ORCs who possess a currently valid certificate of the
type of the system. Back-up ORCs must possess a grade equal to (or no more than one grade less than) the grade
of the system [15A NCAC 8G.0201].
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The ORC of each Class I facility must:
➢ Visit the facility at least'weekly
➢ Comply with all other conditions of 15A NCAC 8G.0204.
The ORC of each Class II', III and IV facility must:
➢ Visit the facility at least five days per week, excluding holidays
➢ Properly manage and document daily operation and maintenance of the facility
➢ Comply with all other conditions of 15A NCAC 8G.02044.
Once the facility, is classified, the Permittee shall submit a letter to the Certification• Commission designating the
operator in responsible charge:
a. Within 60 calendar days prior to wastewater being introduced into' a new' system
b. Within 120 calendar days of.
➢ Receiving notification of a change in the classification of the system requiring the designation of a.
new ORC and back-up ORC
➢ A vacancy in the position of ORC or back-up ORC.
2. Proper Operation and Maintenance
The Permittee shall at all times provide the operation and maintenance resources necessary to operate the existing
facilities at optimum efficiency. The Permittee shall at all times, properly operate and maintain all facilities and
systems of treatment and .control (and related appurtenances) which are installed or used by the Permittee to
achieve compliance with the conditions of this permit. Proper operation and maintenance also'includes adequate
laboratory controls and appropriate quality assurance procedures. This provision requires the Permittee to.install
and operate backup or auxiliary, facilities only' when necessary to achieve compliance with the conditions of the
permit [40 CFR 122.41. (e)].
3. Need to Halt or Reduce not a Defense
It shall not be a defense for a Permittee in an, enforcement action. that it would have been necessary to Halt or
reduce the permitted activity in order to maintain compliance with the condition of this permit [40 CFR 122.41
(c)]
4. Bypassing of Treatment Facilities
a. Bypass not exceeding limitations [40 "CFR 122.41 (m) (2)]
The Permittee may allow any bypass to occur which does not cause effluent limitations to be exceeded, but,
only if it also is for essential maintenance to assure efficient operation. These bypasses are not subject to the
provisions of Paragraphs b. and c. of this section.'- . -
b. Notice [40 CFR 122.41 (m) (3)]
(1) Anticipated bypass. If the Permittee knows in advance of the need for a bypass, it shall submit prior
notice, if possible . at least ten days before the date of the bypass; including an evaluation of. the
anticipated quality and effect of the bypass:
(2) -Unanticipated bypass. The Permittee shall submit notice of an unanticipated bypass as required in Part
II. E. 6. (24-hour notice).
c. Prohibition of Bypass
(1) Bypass from the treatment facility is prohibited and the Permit Issuing Authority may take enforcement .
i action against a Permittee for bypass, unless:
f (A) Bypass was unavoidable to prevent loss of life, personal injury or severe property damage;
(B) There were no feasible alternatives to the bypass, such as the use of auxiliary treatment facilities,
retention of untreated wastes or maintenance during normal periods of equipment downtime. This
condition is not satisfied if adequate backup equipment should have been installed in the exercise of
reasonable engineering judgment to prevent a bypass which occurred during normal periods of
equipment downtime or preventive maintenance; and
(C) The Permittee submitted notices as required under Paragraph b. of this section.
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(2) Bypass from the collection system is prohibited and the Permit Issuing Authority may take enforcement
action against a Permittee for a bypass as provided in any current or future system -wide collection system
permit associated with the treatment facility.
(3) The Permit Issuing Authority may approve an anticipated bypass, after considering its adverse effects, if
the Permit Issuing Authority determines that it will meet the three conditions listed above in Paragraph c.
(1) of this section.
5. Upsets
a. Effect of an upset [40 CFR 122.41 (n) (2)]: An upset constitutes an affirmative defense to an action
brought for noncompliance with such technology based permit effluent limitations if the requirements of
paragraph b. of this condition are met. No determination made during administrative review of claims that
noncompliance was caused by upset, and before an action for noncompliance, is final administrative action
subject to judicial review. `
b. Conditions necessary for a demonstration of upset: A Permittee who wishes to establish the
affirmative defense of upset shall demonstrate,'through properly signed, contemporaneous operating logs, or
other relevant evidence that:
(1) An upset occurred and that the Permittee can identify the cause(s) of the upset;
.(2) The Permittee facility was at the time being properly operated; and
(3) The Permittee submitted notice of the upset as required in Part II. E. 6. (b) of this permit.
(4) The Permittee complied with any remedial measures required under Part II. B. 2. of this permit.
c. Burden of proof [40 CFR 122.41 (n) (4)]: The Permittee seeking to establish the occurrence of an
upset has the burden of proof in any enforcement proceeding.
6. Removed Substances
Solids, sludges, filter backwash, or other pollutants removed in the course of treatment or control of wastewaters
shall be utilized/disposed of in accordance with NCGS 143-215.1 and in a manner such as to prevent any pollutant
from such materials from entering waters of the State or navigable waters of the United States. The Permittee
shall comply with all existing Federal regulations governing the disposal of sewage sludge. Upon promulgation of
40 CFR Part 503, any permit issued by the Permit Issuing Authority for the utilization/disposal of sludge may be
reopened and modified, or revoked and reissued, to incorporate applicable requirements at 40 CFR 503. The
Permittee shall comply with applicable 40 CFR 503 Standards for the Use and Disposal of Sewage Sludge .(when
promulgated) within the time provided in the regulation, even if the permit is not modified to incorporate the
requirement. The Permittee shall notify the Permit Issuing Authority of any significant change in its sludge use
or disposal practices.
7. Power Failures
The Permittee is responsible for maintaining adequate safeguards (as required by 15A NCAC 2H.0124 —
Reliability) to prevent the discharge of untreated or inadequately treated wastes during electrical power failures
either by means of alternate power sources, standby generators or retention of inadequately treated effluent.
Section D. Monitoring and Records
1:� Representative Sampling
Samples collected and measurements taken, as required herein, shall be characteristic of the volume and nature of
the permitted discharge. Samples collected at a frequency less than daily shall be taken on a day and time that is
characteristic of the discharge over the entire period the sample represents. All samples shall be taken at the
monitoring points specified in this permit and, unless otherwise specified, before the effluent joins or is diluted
by any other wastestream, body of water, or substance. Monitoring points shall not be changed without
notification to and the approval of the Permit Issuing Authority [40 CFR 122.41 (j)].
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2. Reporting
Monitoring results obtained during the previous month(s) shall be summarized for each month and reported on a
monthly Discharge Monitoring Report (DMR) Form (MR 1, 1.1, 2, 3) or alternative forms approved by the
Director, postmarked no later than the last calendar day of the month following the completed reporting period.
The first DAM is due on the last day of the month following the issuance of the permit or in the case of a new
facility, on the last day of the month following the commencement of discharge. Duplicate signed copies of
these, and all other reports required herein, shall be submitted to the following address:
NC DENR / Division of Water Quality / Water Quality Section
ATTENTION: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Flow Measurements
Appropriate flow measurement devices and methods consistent with accepted scientific practices shall be selected
and used to ensure the accuracy and reliability of measurements of the volume of monitored discharges. The
devices shall be installed, calibrated and maintained to ensure that the accuracy of the measurements is consistent
with the accepted capability of that type of device. Devices selected shall be capable of measuring flows with a
maximum deviation of less than 10% from the true discharge rates throughout the range of expected discharge
volumes. Flow measurement devices shall be accurately calibrated at a minimum of once per year and maintained
to ensure that the accuracy of the measurements is consistent with the accepted capability of that type of device.
The Director shall approve the flow measurement device and monitoring location prior to installation.
Once -through condenser cooling water flow monitored by pump logs, or pump hour meters as specified in Part I
of this permit and based on the manufacturer's pump curves shallnot be subject to this requirement.
4. Test Procedures
Test procedures for the analysis of pollutants shall conform to the EMC regulations (published pursuant to
NCGS 143-215.63 et. seq.), the Water and Air Quality Reporting Acts, and to regulations published pursuant to
Section 304(g), 33 USC 1314, of the Federal Water Pollution Control Act (as Amended), and 40 CFR 136; or in
the case of sludge use or disposal, approved under 40 CFR 136, unless otherwise specified in 40 CFR 503, unless
other test procedures have been specified in this permit [40 CFR 122.41].
To meet the intent of the monitoring required by this permit, all test procedures must produce minimum
detection and reporting levels that are below the permit discharge requirements and. all data generated must be
reported down to the minimum detection or lower reporting level of the procedure. If no approved methods are
determined capable of achieving minimum detection and reporting levels below permit discharge requirements,
then the most sensitive (method with the lowest possible detection and reporting level) approved method must
be used.
Penalties for Tampering
The Clean Water Act provides that any person who falsifies, tampers with, or knowingly renders inaccurate, any
monitoring device or method required to be maintained under this permit shall, upon conviction, be punished by
a fine of not more than $10,000 per violation, or by imprisonment, for not more than two years per violation, or
by both. If a conviction of a person is for a violation committed after a first conviction of such person under this
paragraph, punishment is a fine of not more than $20,000 per day of violation, or by imprisonment of not more
than 4 years, or both [40 CFR 122.41].
6. Records Retention
Except for records of monitoring information required by this permit related to the Permittee's sewage sludge
use and disposal activities, which shall be retained for a period of at least five years (or longer as required by 40
CFR 503), the Permittee shall retain records of all monitoring information, including:
➢ all calibration and maintenance records
➢ all original strip chart recordings for continuous monitoring instrumentation
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➢ copies of all reports required by this permit
➢ copies of all data used to complete the application for this permit
These records or copies shall be maintained for a period of at least 3 years from the date of the sample,
measurement, report or application. This period may be extended by request of the Director at any time [40 CFR
122.41].
7. Recording Results
For each measurement or sample taken pursuant to the requirements of this permit, the Permittee shall record
the following information [40 CFR 122.41]:
a. The date, exact place, and time of sampling or measurements;
b. The individual(s) who performed the sampling or measurements;
c. The date(s) analyses were performed;
d. The individual(s) who performed the analyses;
e. The analytical techniques or methods used; and
f. The results of such analyses.
8. Inspection and Entry
The Permittee shall allow the Director, or an authorized representative (including an authorized contractor acting
as a representative of the Director), upon the presentation of credentials and other documents as may be required
by law, to;
a. Enter upon the Permittee's premises where a regulated facility or activity is located or conducted, or where
records must be kept under the conditions of this permit;
b. Have access to and copy, at reasonable times, any records that must be kept under the conditions of this
permit;
C. Inspect at reasonable times any facilities, equipment (including monitoring and control equipment), practices,
or operations regulated or required under this permit; and
d. Sample or monitor at reasonable times, for the purposes of assuring permit compliance or as otherwise
authorized by the Clean Water Act, any substances or parameters at any location [40 CFR 122.41 (i)].
Section E Reporting Requirements
1. Change in Discharge
All discharges authorized herein shall be consistent with the terms and conditions of this permit. The discharge
of any pollutant identified in this permit more frequently than or at a level in excess of that authorized shall
constitute a violation of the permit.
2. Planned Changes
The Permittee shall give notice to the Director as soon as possible of any planned physical alterations or
additions to the permitted facility [40 CFR 122.41 (1)]. Notice is required only when:
a. The alteration or addition to a permitted facility may meet one of the criteria for new sources at 40 CFR
. 122.29 (b); or
b. The alteration or addition could significantly change the nature or increase the quantity of pollutants
discharged. This notification applies to pollutants subject neither to effluent limitations in the permit, nor to
notification requirements under 40 CFR 122.42 (a) (1).
c. The alteration or addition results in a significant change in the Permittee's sludge use or disposal practices,
and such alteration, addition or change may justify the application of permit conditions that are different
from or absent in the existing permit, including notification of additional use or disposal sites not reported
during the permit application process or not reported pursuant to an approved land application plan.
3. Anticipated Noncompliance'
The Permittee shall give advance notice to the Director of any planned changes to the permitted facility or other
activities that might result in noncompliance with the permit [40 CFR 122.41 (1) (2)].
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4. Transfers
This permit is not transferable to any person except after notice to the Director. The Director may require
modification or revocation and reissuance of the permit to document the change of ownership. Any such action
may incorporate other requirements as may be necessary under the Clean Water Act [40 CFR 122.41 (1) (3)].
5. Monitoring Reports
Monitoring results shall be reported at the intervals specified elsewhere in this permit [40 CFR 122.41 (1) (4)].
a. Monitoring results must be reported on a Discharge Monitoring Report (DMR) (See Part II. D. 2) or forms
provided by the Director for reporting results of monitoring of sludge use or disposal practices.
b. If the Permittee monitors any pollutant more frequently than required by this permit, the results of such
monitoring shall be included in the calculation and reporting of the data submitted on the DMR.
6. Twenty-four Hour Reporting
a. The Permittee shall report to the Director or the appropriate Regional Office any noncompliance that
potentially threatens public health or the environment. Any information shall be provided orally within 24
hours from the time the Permittee became aware of the circumstances. A written submission shall also be
provided within 5 days of the time the Permittee becomes .aware of the circumstances. The written
submission shall contain a description of the noncompliance, and its cause; the period of noncompliance,
including exact dates and times, and -if the noncompliance has not been corrected, the anticipated time it is
expected to continue; and steps taken or planned to reduce, eliminate, and prevent reoccurrence of the
noncompliance [40 CFR 122.41 (1) (6)].
b. The Director may waive the written report on a case -by -case basis for reports under this section if the oral
report has .been received within 24 hours.
c. Occurrences outside normal business hours may also be reported to the Division's Emergency Response
personnel at [phone], [phone] or [phone].
7. Other Noncompliance
The Permittee shall report all instances of noncompliance not reported under Part II. E. 5 and 6. of this permit at
the time monitoring reports are submitted. The reports shall contain the information listed in Part II. E. 6. of
this permit [40 CFR 122.41 (1) (7)].
8. Other Information
Where the Permittee becomes aware that it failed to submit any relevant facts in a permit application, or
submitted incorrect information in a permit application or in any report to the Director, it shall promptly submit
such facts or information [40 CFR 122.41 (1) (8)].
Noncompliance Notification
The Permittee shall report by telephone to either the central office or the appropriate regional office of the
Division as soon as possible, but in no case more than 24 hours or on the next working day following the
occurrence or first knowledge of the occurrence of any of the following:
a. Any occurrence at the water pollution control facility which results in the discharge of significant amounts,of
wastes which are abnormal in quantity or characteristic, such as the dumping of the contents of a sludge
digester; the known passage of a slug of hazardous substance through the facility; or any other unusual
circumstances.
b. Any process unit failure, due to known or unknown reasons, that render the facility incapable of adequate
wastewater treatment such as mechanical or electrical failures of pumps, aerators, compressors, etc.
c. Any failure of a pumping station, sewer line, or treatment facility resulting in a by-pass directly to receiving
waters without treatment of all or any portion of the influent to such station or facility.
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Persons reporting such occurrences by telephone shall also file a written report within 5 days following first
knowledge of the occurrence.
10. Availability of Reports
Except for data determined to be confidential under NCGS 143-215.3 (a)(2) or Section 308 of the Federal Act, 33
USC 1318, all reports prepared in accordance with the terms shall be available for public inspection at the offices
of the Division. As required by the Act, effluent data shall not be considered confidential. Knowingly making
any false statement on any such report may result in the imposition of criminal penalties as provided for in
NCGS 143-215.1(b) (2) or in Section 309 of the Federal Act.
11. Penalties for Falsification of Reports
The Clean Water Act provides that any person who knowingly makes any false statement, representation, or
certification in any record or other document submitted or required to be maintained under this permit, including
monitoring reports or reports of compliance or noncompliance shall, upon conviction, be punished by a fine of
not more than $25,000 per violation, or by imprisonment for not more than two years per violation, or by both
[40 CFR 122.41].
12. Annual Performance Reports
Permittees who own or operate facilities that collect or treat municipal or domestic waste shall provide an annual
report to the Permit Issuing Authority and to the users/customers served by the Permittee (NCGS 143-215.1C).
The report shall summarize the performance of the collection or treatment system, as well as the extent to which
the facility was compliant with applicable Federal or State laws, regulations and rules pertaining to water quality.
The report shall be provided no later than sixty days after the end of the calendar or fiscal year, depending upon
which annual period is used for evaluation.
PART III
OTHER REQUIREMENTS
Section A. Construction
The Permittee shall not commence construction of wastewater treatment facilities, nor add to the plant's treatment
capacity, nor change the treatment process(es) utilized at the treatment plant unless the Division has issued an
Authorization to Construct (AtC) permit. Issuance of an AtC will not occur until Final Plans and Specifications for
the proposed construction have been submitted by the Permittee and approved by the Division.
Section B. Groundwater Monitoring
The Permittee shall, upon written notice from the Director, conduct groundwater monitoring as may be required to
determine the compliance of this NPDES permitted facility with the current groundwater standards.
Section C. Changes in Discharges of Toxic Substances
The Permittee shall notify the Permit Issuing Authority as soon as it knows or has reason to believe (40 CFR 122.42):
a. That any activity has occurred or will occur which would result in the discharge, on a routine or frequent
basis, of any toxic pollutant which is not limited in the permit, if that discharge will exceed the highest of the
following "notification levels";
(1) One hundred micrograms per liter (100 µg/L);
(2) Two hundred micrograms per liter (200 µg/L) for acrolein and acrylonitrile; five hundred micrograms
per liter (500 µg/L) for 2.4-dinitrophenol and for 2-methyl-4.6-dinitrophenol; and one milligram per liter
(1 mg/L) for antimony;
(3) Five times the maximum concentration value reported for that pollutant in the permit application.
b. That any activity has occurred or will occur which would result in any discharge, on a non -routine or
infrequent basis, of a toxic pollutant which is not limited in the permit, if that discharge will exceed the
highest of the following "notification levels";
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(1) Five hundred micrograms per liter (500 µg/L);
(2) One milligram per liter (1 mg/L) for antimony;
(3) Ten times the'maximum concentration value reported for that -pollutant in the permit application.
Section D. Evaluation of Wastewater Discharge Alternatives
The Permittee shall evaluate all wastewater disposal alternatives and pursue the most environmentally sound
alternative of the reasonably cost effective alternatives. If the facility is in substantial non-compliance with the terms
and conditions of the NPDES permit or governing rules, regulations or laws, the Permittee shall submit a report in
such form and detail as required. by the Division evaluating these alternatives and a plan of action within 60 days of
notification by the Division.
Section E. Facility Closure Requirements
The Permittee must notify the Division at least 90 days prior to the closure of any wastewater treatment system
covered by this permit. The Division may require specific measures during deactivation of the system to prevent
adverse impacts to waters of the State. This permit cannot be rescinded while any activities requiring this permit
continue at the permitted facility.
PART IV
SPECIAL CONDITIONS FOR MUNICIPAL FACILITIES
Section A. Publicly Owned Treatment Works (POTWs)
All POTWs must provide adequate notice to the Director of the following:
1. Any new introduction of pollutants into the POTW from.an indirect discharger, which would be subject to
section 301 or 306 of CWA if it were directly discharging those pollutants; and
2. Any substantial change in the volume or character of pollutants being introduced by an indirect discharger
as influent to that POTW at the time of issuance of the permit.
3. For purposes of this paragraph, adequate notice shall include information on (1) the. quality and quantity of
effluent introduced into the POTW, and (2) any anticipated impact of the change on the quantity or quality
of effluent to be discharged from the POTW.
Section B. Municipal Control of Pollutants from Industrial Users.
Effluent limitations are listed in Part I of this permit. Other pollutants attributable to inputs from
industries using the municipal system may be present in the Permittee's discharge. At such, time as
sufficient information becomes available to establish limitations for such pollutants, this permit may be
revised to specify effluent limitations for any or all of such other pollutants in accordance with best
practicable technology or water quality standards.
2. Under. no circumstances shall the Permittee allow introduction of the following wastes in the waste
treatment system:
a. Pollutants which create a fire or explosion hazard in the POTW, including, but not limited to,
wastestreams with a closed cup flashpoint of less than 140 degrees Fahrenheit or 60 degrees
Centigrade using the test methods specified in 40 CFR 261.21;
b. Pollutants which will cause corrosive structural damage to the POTW, but in no case Discharges
with pH lower than 5.0, unless the works is specifically designed to accommodate such Discharges;
c. Solid or viscous pollutants in amounts which will cause obstruction to the flow in the POTW
resulting in Interference;
d. Any pollutant, including oxygen demanding pollutants (BOD, etc.) released in a Discharge at a flow
rate and/or pollutant concentration which will cause Interference with the POTW;
e. Heat in amounts which will inhibit biological activity in the POTW resulting in Interference, but in
no case heat in such quantities that the .temperature at the POTW Treatment Plant exceeds 40°C
(104°F) unless the Division, upon request of the POTW, approves alternate temperature limits;
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f. Petroleum oil, nonbiodegradable cutting oil, or products, of mineral oil origin in amounts that will
cause interference or pass through;
g. Pollutants which result in the presence of toxic gases, vapors, or fumes within the POTW in a
quantity that may cause acute worker health and safety problems;
h. Any trucked or hauled pollutants, except at discharge points designated by the POTW.
3. With regard to the effluent requirements listed in Part I of this permit, it may be necessary for the
Permittee to supplement the requirements of the Federal Pretreatment Standards (40 CFR, Part 403) to
ensure compliance by the Permittee with all applicable effluent limitations. Such actions by the Permittee
may be necessary regarding some or all of the industries discharging to the municipal system.
4. The Permittee shall require any industrial discharges sending influent to the permitted system to meet
Federal Pretreatment Standards promulgated in response to Section 307(b) of the Act. Prior to accepting
wastewater from any significant industrial user, the Permittee shall either develop and submit to the
Division a Pretreatment Program for approval per 15A NCAC 2H .0907(a) or modify an existing
Pretreatment Program per 15A NCAC 2H .0907(b).
This permit shall be modified, or alternatively, revoked and reissued, to incorporate or modify an approved
POTW Pretreatment. Program or to include a compliance schedule for the development of a POTW
Pretreatment Program as required under Section 402(b)(8) of the Clean Water Act and implementing
regulations or by the requirements of the approved State pretreatment program, as appropriate.
Section C. Pretreatment Programs
Under authority of sections 307(b) and (c) and 402(b)(8) of the Clean Water Act and implementing regulations 40
CFR Part 403, North Carolina General Statute 143-215.3 (14) and implementing regulations 15A NCAC 2H
.0900, and in accordance with the approved pretreatment program, all provisions and regulations contained and
referenced in the Pretreatment Program Submittal are an enforceable part of this permit.
The Permittee shall operate its approved pretreatment program in accordance with Section 402(b)(8) of the Clean
Water Act, the Federal Pretreatment Regulations 40 CFR Part 403, the State Pretreatment Regulations 15A
NCAC 2H .0900, and the legal authorities, policies, procedures, and financial provisions contained in its
pretreatment program submission and Division approved modifications there of. Such operation shall include
but is not limited to the implementation of the following conditions and requirements:
Sewer Use Ordinance (SUO)
The Permittee shall maintain adequate legal authority to implement its approved pretreatment program.
2. Industrial Waste Surve)(IWS)
The Permittee shall update its Industrial Waste Survey (IWS) to include all users of the sewer collection
system at least once every five years.
3. Monitoring Plan
The Permittee shall implement a Division -approved Monitoring Plan for the collection of facility specific
data to be used in a wastewater treatment plant Headworks Analysis (HWA) for the development of
specific pretreatment local limits. Effluent data from the Plan shall be reported on the DMRs (as required
by Part II, Section D, and Section E.S.).
4. Headworks Anal sis HWA) and Local Limits
The Permittee shall obtain Division approval of a Headworks Analysis (HWA) at least once every five
years, and as required by the Division. Within 180 days of the effective date of this permit (or any
subsequent permit modification) the Permittee shall submit to the Division a written technical evaluation
of the need to revise local limits (i.e., an updated HWA or documentation of why one is not needed) [40
CFR 122.44]. The Permittee shall develop, in accordance with 40 CFR 403.5(c) and 15A NCAC 2H .0909,
specific Local Limits to implement the prohibitions listed in 40 CFR 403.5(a) and (b) and 15A NCAC 2H
.0909.
Version 1011012007

NPDES Permit Standard Conditions
Page 15 of 16
5. Industrial User Pretreatment Permits (!UP) & Allocation Tables
In accordance with NCGS 143-215.1, the Permittee shall issue to all significant industrial users, permits for
operation of pretreatment equipment and discharge to the Permittee's treatment works. These permits
shall contain limitations, sampling protocols, reporting requirements, appropriate standard and special
conditions, and compliance schedules as necessary for the installation of treatment and control
technologies to assure that their wastewater discharge will meet all applicable pretreatment standards and
requirements. The Permittee shall maintain a current Allocation Table (AT) which summarizes the results
of the Headworks Analysis (HWA) and the limits from all Industrial User Pretreatment Permits (IUP).
Permitted IUP loadings for each parameter cannot exceed the treatment capacity of the POTW as
determined by the HWA.
6. Authorization to Construct (AtQ
The Permittee shall ensure that an Authorization to Construct permit (AtC) is issued to all applicable
industrial users for the construction or modification of any pretreatment facility. Prior to the issuance of
an AtC, the proposed pretreatment facility and treatment process must be evaluated for its capacity to
comply with all Industrial User Pretreatment Permit (IUP) limitations.
7. POTW Inspection & Monitoring of their SIUs
The Permittee shall conduct inspection, surveillance, and monitoring activities as described in its Division
approved pretreatment program in order to determine, independent of information supplied by industrial
users, compliance with applicable pretreatment standards. The Permittee must:
a. Inspect all Significant Industrial Users (SIUs) at least once per calendar year; and
b. Sample all Significant Industrial Users (SIUs) at least twice per calendar year for all permit -
limited pollutants, once during the period from January 1 through June 30 and once during the
period from July 1 through December 31, except for organic compounds which shall be sampled
once per calendar year;
SIU Self Monitoring and Reporting
The Permittee shall require all industrial users to comply with the applicable monitoring and reporting
requirements outlined in the Division -approved pretreatment program, the industry's pretreatment permit,
or in 15A NCAC 2H .6908.
9. Enforcement Response Plan (ERP)
The Permittee shall enforce and obtain appropriate remedies for violations of all pretreatment standards
promulgated pursuant to section 307(b) and (c) of the Clean Water Act (40 CFR 405 et. seq.), prohibitive
discharge standards as set forth in 40 CFR 403.5 and 15A NCAC 2H .0909, and specific local limitations.
All enforcement actions shall be consistent with the Enforcement Response Plan (ERP) approved by the
Division.
10. Pretreatment Annual Reports , ARl
The Permittee shall report to the Division in accordance with 15A NCAC 2H .0908. In lieu of submitting
annual reports, Modified Pretreatment Programs developed under 15A NCAC 2H .0904 (b) may be
required to meet with Division personnel periodically to discuss enforcement of pretreatment requirements
and other pretreatment implementation issues.
For all other active pretreatment programs, the Permittee shall submit two copies of a Pretreatment
Annual Report (PAR) describing its pretreatment activities over the previous twelve months to the
Division at the following address:
NC DENR / DWQ / Pretreatment Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Version 1011012007

s �
NPDES Permit Standard Conditions
Page 16 of 16
These reports shall be submitted according to a schedule established by the Director and shall contain the
following:
a.) Narrative
A brief discussion of reasons for, status of, and actions taken for all Significant Industrial
Users (SIUs) in Significant Non -Compliance (SNC);
b.) Pretreatment Program SummaU (PPS)
A pretreatment program summary (PPS) on specific forms approved by the Division;
c.) Significant Non -Compliance Report (SNCR)
The nature of the violations and the actions taken or proposed to correct the violations on
specific forms approved by the Division;
d.) Industrial Data Summary Forms M2SQ
Monitoring data from samples collected by both the POTW and the Significant Industrial
User (SIU). These analytical results must be reported on Industrial Data Summary Forms
JDSF) or other specific format approved by the Division;
e.) Other Information
Copies of the POTW's allocation table, new or modified enforcement compliance schedules,
public notice of SIUs in SNC, and any other information, upon request, which in the
opinion of the Director is needed to determine compliance with the pretreatment
implementation requirements of this permit;
11. Public Notice
The Permittee shall publish annually a list of Significant Industrial Users (SIUs) that were in Significant
Non -Compliance (SNC) as defined in the Permittee's Division -approved Sewer Use Ordinance with
applicable pretreatment requirements and standards during the previous twelve month period. This list
shall be published within four months of the applicable twelve-month period.
12. Record Keeping
The Permittee shall retain for a minimum of three years records of monitoring activities and results, along
with support information including general records, water quality records, and records of industrial impact
on the POTW.
13. Funding and Financial Report
The Permittee shall maintain adequate funding and staffing levels to accomplish the objectives of its
approved pretreatment program.
14. Modification to Pretreatment Programs
Modifications to the approved pretreatment program including but not limited to local limits
modifications, POTW monitoring of their Significant Industrial Users (SIUs), and Monitoring Plan
modifications, shall be considered a permit modification and shall be governed by 15 NCAC 2H .0114 and
15A NCAC 2H .0907.
Version 1011012007

SOC PRIORITY PROJECT:
To: Western NPDES Unit
Surface Water Protection Section
Attention: Charles Weaver
Date: October 22, 2008
NPDES STAFF REPORT AND RECOMMENDATIONS
County: Iredell
NPDES Permit No.: NCO045012
PART I - GENERAL INFORMATION
1. Facility and address: Hill Haven Residential Care
224 Augusta Drive
Statesville, NC 28625
2. Date of investigation: October 2, 2008
3. Report prepared by: B. Dee Browder, Environmental Engineer
4. Person contacted and telephone number: Dena Myers, Statesville Analytical, Inc.,
(704)4372402
5. Directions to site: From the jet. of Hwy 21/115 and Old Mountain Road in Troutman
travel north on Hwy 21/115 approximately 2.2 miles and turn left onto Hill Haven Road.
Turn right onto Schafer Hollow Drive. The facility is on the right side of the drive
approximately 2'50 feet from the entrance in the woods.
6. Discharge point(s): Latitude:35° 44' 45"
Longitude: 800 53' 44"
USGS Quad No.: Troutman, NC
7. Receiving stream or affected surface waters: UT to Third Creek
a. Classification: C.
b. River Basin and Subbasin No.: Yadkin 030706
C. Describe receiving stream features and pertinent downstream uses: Receiving
stream is 6-8 feet wide and 12-18 inches deep at the time of the inspection.

Page Two
PART II - DESCRIPTION OF DISCHARGE AND TREATMENT WORKS
1. a. Volume of wastewater: 0.018 MGD (Design Capacity)
b. What is the current.permitted capacity: 0.018 MGD
C. Date(s) and construction activities allowed by previous ATCs issued in the
previous two years: N/A
d. Description of existing or substantially constructed WWT facilities: The existing
WWT facilities consist of two septic tanks and two surface sand filters, effluent
chlorination and declorination.
e. Description of proposed WWT facilities: N/A
f. Possible toxic impacts to surface waters: There are no toxic impacts expected.
g. Pretreatment Program (POTWs only): Not Needed.
2. Residual handling and utilization/disposal scheme: N/A
a. If residuals are being land applied specify DWQ Permit No. Not generated at this
time.
3. Treatment plant classification: Class (no change from previous rating).
4. Compliance Background: Good
PART III - OTHER PERTINENT INFORMATION
1. Special monitoring or limitations (including toxicity) requests: None at this time.
2. Important SOC/JOC or Compliance Schedule dates: N/A
3. Alternative analysis evaluation
a. Spray Irrigation: N/A.
b. Connect to regional sewer system:N/A
C. Subsurface: N/A
d. Other disposal options: N/A

Page Three
PART IV - EVALUATION AND RECOMMENDATIONS
The facility has not been operating for a number of years and the equipment associated with the
treatment facility shows signs of lack of maintenance. The declorination unit has been removed
and could not operate at this time. Structural walls surrounding the filter beds need repair and the
cover of the splitter box needs to be replaced. Access is not available to observe the condition of
the other components of the system but other items of the system need to be inspected prior to
putting the system back in service. MRO recommends that a condition be put in the permit that
requires a PE to inspect and certify all components of the system, including the collection system
lines, prior to the system being puta in operation.
Signature of Report Preparer ° /Date
D 10
Water Quality Regional Supervisor Date
h:\dsr\dsr08\.dsr

�QF W ATFIQQ Michael F. Easley, Governor
William G. Ross Jr., Secretary.
r. North Carolina Department of Environment and Natural Resources
p Coleen H. Sullins, Director
September 24, 2008
PAMELA E FORD
PRESIDENT
HILL HAVEN RESIDENTIAL CARE
224 AUGUSTA DRIVE
STATESVILLE NC 28625
Dear Ms. Ford:
SEP 2 '6 2008
MRO
DWQ-Surface WOter PrOtection
Subject: Receipt of permit renewal application
NPDES Permit NCO045012
Hill Haven Residential Care
Iredell County
The NPDES Unit received'your permit renewal application on September 24, 2008. A
member of the NPDES Unit will review your application. They win contact you if additional
information is required to complete your permit renewal. You should 'expect to receive a draft
permit approximately 30-45 days before your existing permit expires.
If you have any additional questions concerning renewal of the subject permit, please contact
Charles Wever at [phone].
Sincerely,
S4��4ol,c��
Dina Sprinkle
NPDES Unit
cc: • CENTRAL FILES
jhbg&sLlRre on�ce/Surface Water Protection
NPDES Unit
Mailing Address Phone [phone] Location One
X5fthCaro)
1617 Mail Service Center Fax [phone] N. Salisbury St. Naturally
Raleigh, NC 27699-1617 Raleigh, NC 27604
Internet: wwwmcwateraualitv.ore Customer Service 1-877-623-6748
An Equal OpportunitydAffirmalive Mon Employer— 50% Recycled/10% Post Consumer Paper

01
RECEIVED
SEP 2 4 2008
DENR - WATER OUALITY
POINT SOURCE BRANCH
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NPDES APPLICATION - FORM D
For privately owned treatment systems treating 100% domestic wastewaters <1.0 M-
_ai; the complete application to:
N_ C. DENR / Division of Water Quality / NPDES Unit
1617 Mail Service Center,_ Raleigh, NC 27699-1617
NPDES Permit $C00
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
Facility Name
i �'
i t ly m_P,
e j C e- V i cR r T_� C, f
Mailing Address
Uel V
city
am -es e
�
State / Zip CodeQ,4
`j
Telephone Number
Fax Number
e-mail Address
SEP 2 4 2008
2. Location of facility producing discharge:
Check here if same address as above El
Street Address or State Road .1 ((...I.
city
State / Zip Code
L�7
DENR - WATER OUALITY
POINT SOURCE BRANCH
Mvem Ra-=
l
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 �' �'� ��� � �� �IL
Mailing Address
city
State / Zip Code
Telephone Number
Fax Number ( )
�'-°•.d �X.+� �...`L:'�.�� m Tom"' 9 `�..• V�itl�^-�i _
1 of 3 Form-D 05/08

NPDES APPLICATION - FORM 13
For privately owned treatment systems_ treating. 100% domestic wastewaters <1.0 MGD
yr. "esen-ption of wasTewater:
1 Facility Generating Wastewater(check all that apply):
i
Industrial
❑ /
Number of Employees
Commercial
Number of Employees
Residential
❑
Number of Homes
School
❑
Number of Students/Staff
ti thA cr
M
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
W, eel
Poaulation served: ; 11
6. Type.,of collection system
520"Separate (sanitary sewer only)
6. Gutfali Information:
❑ Combined (storm sewer and sanitary sewer)
Number of separate discharge points )
Gut€all Identification number(s) L-11
f.
Is the outfail equipped with_a diffuser? ❑ Yes o
?. Nan�e of receiving stream(s) (Provide a map showing the exact location of each outfail):
e_ i .1 C °
8. Frequency of Discharge: ❑ Continuous [Intermittent
If intermittent:
Days per week discharge occurs: �% Duration: _
9. 'Describe Una treatment SySr6eM
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.
2 of 3 Form-D OS/08

For privately owned treatment systems treating 100% domestic wastewaters <1:0 MGD
10. Flow Information:
Treatment ]Plant Design flow C3P 0 ('� MGD
Anpual Average daily flow MCID (for the previous 3 years.)
Maximum daily flow MGD (for the previous 3 years)
11. Is this facility located on Indian country?
F1 Yes �No
12,' Eff]l pnt Data
Provide data for the parameters listed. Fecal Coliform, Temperature and pH shall be grab samples, for all other
crrameters 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 (BOD5)
Fecal Coliform
Total Suspended Solids
Temperature (Summer)
Temperature (Winter)
pH
13. List all permits, construction approvals and/or applications:
Type Permit Number Type
Hazardous Waste (RCRA) NESHAPS (CAA)
UIC (SDWA)
NPDES
PSD (CAA)
Non -attainment program (CAA)
14. APPLICANT CERTIFICATION
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.
name of Person Signing
r-
Signature of Applicant
Title
111
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 implementina. 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 IForm-D 05108

J
� a e

i
SOC PRIORITY PROJECT: Yes_ No X
To: Permits and Engineering Unit
Water Quality Section
Attention: Carolyn Bryant
Date: August 12, 2004
NPDES STAFF REPORT AND RECOMMENDATION
County: Iredell
MRO# 04-62
Permit No. NCO045012
PART I GENERAL INFORMATION
1. Facility and address: Hill Haven Residential Care, Inc.
114 Hill Haven Road
1000-4 North First Street
Statesville, North Carolina 28677
2. Date of investigation: August 10, 2004
3. Report prepared by: Samar Bou-Ghazale, Env. Engineer.I
4. Persons contacted -and telephone number: Mr. -.Jerry Rogers, ORC, [phone].
5. Directions to site: From the junction of Highway 21 /115 and Old Mountain Road (SR 1005)
in Troutman, Iredell County, travel north on Highway 21 /115 approximately 2.2 miles to the
junction with Hdl Haven.Road (SR 1381). Turn left on Hill Haven Road and travel
approximately 300 feet to the intersection with Schafer Hollow Drive. Turn right on Schafer
Hollow Drive and proceed approximately 100 feet to the nursing facilities located on both
sides of the road
6. Discharge point(s). List for all discharge points:
Latitude: 35 ° 44' 45" Longitude: 80 ° 53' 44"
Attach a U.S.G.S. map extract and indicate treatment facility site and dischargepoim onmap.
USGS Quad No.: E 15 NW USGS Name: Troutman, NC
7. Site size and expansion area consistent with application?
Yes X No_ If No, explain:
8. Topography (relationship to flood plain included): Facilities are not located in the 100-year
X

a
flood plain. ,Slopes range from 3- 15%.
9. Location of nearest dwelling: Approximately 200 feet
10. Receiving stream or -'affected surface waters: ' UT to Third Creek.
a. Classification: C
b. River Basin and Subbasin No,: Yadkin -Pee Dee & 03-07-06
c. Describe receiving stream features and pertinent downstream uses: Flowwas observed
in the ' .'receiving stream which was approximately 3' 'wide and 2-3 inches deep.
Downstream uses are typical for class C. waters.
PART H -DESCRIPTION OF DISCHARGE AND TREATMENT WORKS
1: a. Volume of wastewater to be permitted: 0.018 MGD (Ultimate Design Capacity) .
b. What is the current permitted capacity of the wastewater treatment facility? 0.018
MGD
c. Actual treatment capacity of the current facility (current design capacity)? 0.018
MGD
d. Date(s), and construction activities allowed by previous Authorizations to Construct
issued is .the previous two years: N/A.
e. Please provide a description of existing or substantially constructed wastewater
treatment'facilities: The existing`facilitim consists oftwo septic tanks and two surface
sand filters operated 'in parallel, and effluent chlorination with a contact basin. The
combined flow is 18,000 GPD and is discharged via a single outfall line: The WWT P
is not in operation, at this time.
f. Please provide a description of proposed wastewater treatment facilities: N/A-
g. Possible toxic impacts to surface waters: NIA -
IL Pretreatment Program (POTWs only): N/A.
2. Residuals handling and utilization/disposal scheme:
Sludge is removed as necessary by Lentz Septic Tank Service and disposed of at a septage land
application site approved by the DWM (SEAS-49-01).
Page 2

3. Treatment plantclassification (attach completed rating sheet): Class I (no change ofrating,
no rating sheet attached).
4. SIC Code(s): 8051
Primary: 11 'Secondary:
Main Treatment Unit Code: 44013
PART III - OTHER PERTINENT INFORMATION
.1. Is this facility .being constructed with Construction, Grant -Funds or are any public monies
involved (municipals only)? N/A.
2. Special monitoring or limitations -(including to)dcity)'requests: None-.
3. Important SOC,_JOC or Compliance Schedule dates: N/A
4. Alternative Analysis Evaluation: (Has the facility evaluated all of the non -discharge options
available. Please provide regional perspective for each option evaluated): N/A
5. Air quality and/or groundwater concerns or hazardous materials utilized at this facility that
may impact water quality, air quality or groundwater? No known air quality, groundwater
or hazardous materials concerns.
6. Other Special Items: The wastewater treatment facility is not in operation, therefore, there
-is no flow to the WWTP. Facility has been closed for approximately 1 year.
PART, -IV: EVALUATION AND, RECOMMENDATIONS'
The Permittee, •Pamela. Edwards Ford, is applying for renewal of the facility's NPDES
permit to discharge treated domestic wastewater from two septic tank sand filter systems serving
Hill Haven Residential Care, Inc. Pending review and approval by the P&E, it is recommended
that the, permit be renewed as requested.
't/ ifs
Water Ouali�
v _ r
.Date
Page 3

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NCDENR
it
Pamela Edwards Ford
President
114 Hill Haven Rd.
Statesville, North Carolina 28677
Dear Ms. Ford:
SR? Michael F. Easley
Governor
William G. Ross, Jr., Secretary
North Carolina Department of Environment and Natural Resources
;W,,Kli,mek. ,P.E:;,,Director
Coffee Sull"ins, Division -Director
Divisionof WaiWbuality
p'1 I
June 28, 2004
JUN 2 9 2004
Subject: Receipt of permit renewal application
NPDES Permit NCO045012
Hill Haven Residential Care V)TP
Iredell County
The NPDES Unit received your permit renewal application on June 26, 2004: A member of the NPDES
Unit will review your application. That staff member will contact you if additional information is required to
complete your permit renewal. You should expect to receive a draft permit, approximately 30-45 days before .your
existing permit expires. The requirements in your existing permit will remain in effect until the permit is
renewed (or the Division takes other action).
If you have any additional questions concerning renewal of the subject permit, please contact me at (919)
733-5083, extension 520.
Sincerely,
cw'tw btu
Carolyn Bryant
Point Source Branch,
cc: CEN_ TRAL_FILES _
Mooresville Regional Office%Water-Quality-Section_ _
NPDES Unit
N. C. Division of Water Quality / NPDES Unit Phone: [phone] Fax: (919) 7ZO119
1617 Mail Service Center, Raleigh, NC 27699-1617 DENR Customer Service Center: 1 800 623-7748
Internet: h2o.enr.state.nc.us e-mail: Carol [e-mail]

142 Oak Haven Drive
Statesville, NC 28625
June 21, 2004
Teresa Rodriguez
DWQ - Point Source Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Re: Renewal Notice
NPDES Permit NCO045012
Hill Haven Residential Care, Inc.
Iredell County
Dear Madam:
I received the renewal notice for the above NPDES Permit on Saturday, June 19, 2004.
In our telephone conversation on June 11, 2004, I explained that I had never received the
first renewal notice dated January, 2004. Hill Haven is not operating at the present time;
therefore, I can only assume that since there is no mail delivery to the 114 Hill Haven
Road address, that the post office did not forward the first notice to my home address,
which is now the address for Hill Haven. Had I received the original notice of renewal, I
would have responded within the proper time limit. I have always complied with time
requirements in the past, and am well aware of the importance of doing so; therefore, I
respectfully request that the enclosed application be allowed to renew NPDES Permit
0045012.
Please be advised that the septic system is pumped when the ORC gives notification.
Lentz Septic Tank Service last pumped the tanks on April 16, 2003.
Thank you for your understanding and your assistance regarding this matter.
Sincerely,
Pamela Edwards Ford, President
Hill Haven Residential Care, Inc.
Enclosure

NPDES APPLICATION FOR PERMIT RENEWAL- SHORT FORM D
To be filed only by privately -owned dischargers of 1.00% domestic wastewater 1<1 MGD flow)
N. C. Department of Environment and Natural Resources
Division of Water (,duality / NPDES. Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
http://h2o.enr.state.nc.us/NPDES/
North Carolina. NPDES .Permit.Number < NC00 . 0-.1
Please print or type
1. Contact Information:
Facility Name
Owner Name
Street Address
City
State / Zip Code
Telephone Number
Fax Number
e-mail Address
Operator Name
Street Address
City
State / Zip Code
County
Telephone Number
1A11M IAUC-n '1�eslcke-ll lal Ukre> J-nc�P
2. Location of facility producing discharge:
Check here if same as above LEI
Facility Name (If different from above)
` Street Address or State Road
City
State / Zip Code
County
3. Reason for application:
Expansion/Modification * Existing Unpermitted Discharge
Renewal _ New Facility
* Provide a description of the expansion/.modification:
Page 1 of 3 Version 12102

` - NPDES APPLICATION FOR PERAUT RENEWAL- SHORT FORM D
To be filed only by privately -owned dischargers of 100% domestic wastewater (<1 MGD flow)
4. Description of the existing treatment facilities (list all installed components with
capacities):
5. Description of wastewater (check all that.app(y):
'lope of Facility Generating Wastewater
Industrial Number of Employees
Commercial- - Number of Employees—
Residential Number of Homes
School Number of Students/Staff
Other k,�—
Describe the source(s) of wastewater (ekample: subdivision, mobile home park, etc.):
6. List all permits, construction approvals and/or applications (check all that apply):
Type Permit Number Tye Permit Number
RCRA Non -Attainment
UIC Ocean Dumping
NPDES 60 o la Dredge/Fill Permits
PSD Other
aM�NIMR0
7. Number of separate wastewater discharge pipes (wastewater outfalls): �� +
8. If the facility has multiple discharge outfalls, record the source(s) of wastewater for each
outfall:
R
9. Name of receiving stream(s) (Provide a map showing the exact location of each outfalp:
D i11e-f %cxSi f
Page 2 of 3 Version 12102

WE - � . T RENEWAL- SHORT FORM D
NPDES APPLICATION FOR PERIVII
o be filed only by privately -owned dischargers of 100% domestic wastewater (<1 MGD flow)
T
I
10. Is this facility located on Native American lands? (c tone)
E.
YS NO
familiar with the information contained in the application and that to
I certify that I am fa dg complete,.and accurate.
the best of mp knowledge and belief such information is true. comp
Name of -person Signing
North Carolina General Statute 143-215.6(b)(2) provides that: Any person who knowingly makes any false statement
representation, or.certification Statute
in any application, record, report, plan, or other document files or required'to be maintained under
tampers with,
cle, or who falsffi
Article 21 or regulations of the Environmental Management
monitoring dev ce olon implementing th
at rr method required to be 'perated or maintained runder
or knowingly renders inaccurate any recordingat Article, shall be guilty of
Article 21 or regulations of the Environmental Management
Comm r by imprisonmentnment not to ession implementingxceed six months, or by both. (18 U.S.C.
misdemeanor punishable by a fine not to exceed $ O
Section 1001 provides a punishment by a fine of not more than $10,000 or imprisonment not more than 5 years, or both for a
similar offense.)
Version 12102

rl,-
Michael r. Easley, Governor
Willinm G. Ross Jr.. Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimck, P. E. Director
Division ofN aterQuality
DIVISION OF WATER QUALITY
December 23, 2004
Ms. Pamela Edwards Ford
President
114 Hill Haven Road
Statesville, North Carolina 28677.
Subject: NPDES Permit No. NCO045012
Hill Haven Residential Care WWTP
Iredell County, NC
Dear Ms. Ford:
Our records indicate that NPDES Permit No. NCO045012 was issued on December 15, 2004
for the discharge of wastewater to the surface waters of the State from your facility. The purpose
of this letter is to advise you of the importance of the Permit and the liabilities in the event of failure
to comply with the terms and conditions of the Permit. If you have not already done so, it is
suggested that you thoroughly read the Permit. Of particular importance is Page 4.
Page 4 sets forth the effluent limitations and monitoring requirements for your discharge.
Your discharge must not exceed any of the limitations set forth. The section headed "Monitoring
Requirements" describes the measurement frequencies, sample types and sampling locations. Upon
commencement of your discharge (or operation), you must initiate the required monitoring. The
monitoring results must be entered on reporting forms furnished or approved by this Agency. If you
have not received these forms, they should be arriving shortly. If you fail to receive the forms, please
contact this Office as quickly as possible. I have enclosed a sample of the "Effluent" reporting form
(DWQ Form MR-1), plus instructions for completing the form. It is imperative that all applicable
parts be completed, and the original and one copy be submitted as required.
Please be advised that an annual administering and compliance monitoring fee may be
required for your facility. You will soon be receiving a statement from our Raleigh Office. It is
imperative that the fee be paid in a timely manner so as to prevent enforcement action or possible
revocation of your permit.
col-diCarolina 1
t'rTllfl7l�% A'V
1ACDEP R
N. C. Division of Water Quality, Mooresville Regional Office, 610 E. Center Ave. Suite 301, Mooresville NC 28115 [phone] Customer Service
1-877-623-6748

The remaining parts of the Permit set forth definitions, general conditions and special
conditions applicable to the operation of wastewater treatment facilities and/or discharge(s). The
conditions include special reporting requirements in the event of noncompliance, bypasses, treatment
unit/process failures, etc. Also addressed are requirements for a certified wastewater treatment plant
operator if you are operating wastewater treatment facilities. Any changes in operation of
wastewater treatment facilities, quantity and type of wastewater being treated or discharged,
expansions and/or upgrading of wastewater treatment facilities must be permitted or approved by
this Agency.
Failure to comply with the terms and conditions of an NPDES Permit subjects the Permittee
to enforcement action pursuant to Section 143-215.6 of the North Carolina General Statutes. A civil
penalty of up to $25,000 per violation (and/or criminal penalties) may be assessed for such
violations. If you find at any time that you are unable to comply with the terms and conditions of
the Permit, you should contact this Office immediately. A Special Order by Consent (SOC) may be
necessary while pursuing action to obtain compliance.
As a final note, an NPDES Permit is normally issued for a five-year period. Permits are not
automatically renewed.. Renewal requests must be submitted to this Agency no later than 180 days
prior to expiration. Please make note of the expiration date of your Permit. This date is set forth on
Page 1 of the Permit. Also note that NPDES Permits are not automatically transferable. If you, as
the Permittee, cease to need this Permit, then you should request that the Division of Water Quality
rescind the Permit or request that DWQ reissue the Permit to another party, if necessary.
As mentioned previously, the purpose of this letter is to advise you of the importance of your
NPDES Permit. Please read the Permit and contact this Office at 704/663-1699 in Mooresville if
you have any questions or need clarification. We look forward to providing any assistance.
incerely,
D. Rex Gleason, P.E.
Water Quality Regional Supervisor
Enclosure
A:\NPDESLTR.WQ

OF WAT�c�
=0:
uo- W",, i Lk%j'
Michael F. Easley, Governor
State of North Carolina
r„:9 4'.::i`i.• ''°••w�• ?J PCWllliam G. Ross, Jr., Secretary
CIi3 ^: Departrrfetit:'ofEnviroriinent and Natural Resources
a Alan W. Klimek, P.E., Director
Division of Water Quality
December 15, 2004 DEC 2 2 2004
Ms. Pamela Edwards Ford
President
114 Hill Haven Road
Statesville North Carolina 28677 b V
Subject: Issuance of NPDES Permit
NCO045012
Hill Haven Residential Care WWTP
Iredell County
Dear Ms. Edwards Ford:
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 May 9,1994 (or
as subsequently amended).
This final permit includes no major changes from the draft permit sent to you on August 18,
2004.
This permit includes a TRC limit that will take effect on July 1, 2006. If you wish to install
dechlorination equipment, the Division has promulgated a simplified approval process for such projects.
Guidance for approval of dechlorination projects is attached.
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 Toya Fields at telephone number [phone], extension 551.
Sincerely,
ORIGINAL WNED B
SUSAN A. WILSON
Alan W. Klimek, P.E.
cc: Central Files
Mooresville Regional Office/Water Quality Section i
NPDES Unit
North Carolina Division of Water Quality [e-mail] - [phone] x551
1617 Mail Service Center FAX [phone]
Raleigh, North Carolina 27699-1617 On the Internet at http://h2o.enr.state.nc.usl

Permit NCO045012
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
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,
Hill Haven Residential Care, Inc.
is hereby authorized to discharge wastewater from a facility located at the
Hill Haven Residential Care
114 Hill Haven Road
Statesville
Iredell County
to receiving waters designated as an unnamed tributary to Third Creek in the Yadkin -
Pee Dee River Basin in accordance with effluent limitations, monitoring requirements,
and other conditions set forth in Parts I, II, III, and IV hereof.
The permit shall become effective January 1, 2005.
This permit and the authorization to discharge shall expire at midnight on March 31, 2009.
Signed this day December 3, 2004.
ORIGINAL SIGNED BY
SUSAN A. @91 LSON
Alan W. Klimek, P.E., Director
Division of Water Quality
By Authority of the Environmental Management Commission

Permit NCO045012
SUPPLEMENT TO PERMIT COVER SHEET
All previous NPDES Permits issued to this facility, whether for operation or discharge are hereby revoked. As of this
permit 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.
Hill Haven Residential Care, Inc., is hereby authorized to:
1. Continue to operate an existing 0.018 MGD wastewater treatment plant
consisting of the following components:
. Two septic tanks
• Two surface sand filters
• Effluent chlorination
The facility is located at Hill Haven Residential Care at 114 Hill Haven Road
near Statesville in Iredell County.
2. Discharge from said treatment works at the location specified on the attached
map into an unnamed tributary to Third Creek, classified as C waters in the
Yadkin -Pee Dee River Basin.

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Discharge location
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ill Haven Residential Care WWTP — NCO045012
Facility
Location
USGS Quad Name: Troutman
Lat.: 35044'50"
Receiving Stream: UT to Third Creek
Long.: 80°53'41"
Stream Class: C
Subbasin: Yadkin Pee Dee — 03-07-06
North Not to SCALE

Permit NCO045012
A.(1) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS
During the period beginning on the effective date of the permit and lasting until expiration, the
Permittee is authorized to discharge from outfall serial number 001. Such discharges shall be
limited and monitored by the Permittee as specified below:
EFFLUENT
CHARACTERISTICS
...
LIMITS
_
MONITORING, REQUIREMENTS
Monthly
Weekly
Daily
Measurement
Sample
Sample _ -'
Average
Average
:Maximum
Frequency
Type
Location'
Flow
0.018 MGD
Weekly
Instantaneous
I or E
BOD, 5 day, 20 °C
30.0 mg/L
45.0 mg/L
2/Month
Grab
E
Total Suspended Solids
30.0 mg/L
45.0 mg/L
2/Month
Grab
E
NH3 as N
(April I to October 31)
9.4 mg/L
35.0 mg/L
2/Month
Grab
E
NH3 as N
(November 1 to March 31)
30.0 mg/L
35.0 mg/L
2/Month
Grab
E
Fecal Coliform
(geometric mean)
200/100 mL
400/100 mL
2/Month
Grab
E
Total Residual Chlorine2
28.0 µg/L
2/Week
Grab
E
Temperature
Weekly
Grab
E
Total Nitrogen
Quarterly
Grab
E
(NO2 + NO3 + TKN)
Total Phosphorus
Quarterly
Grab
E
PH
Between 6 and 9 s.u.
2/Month
Grab
E
Notes:
1. Sample locations: I — Influent, E — Effluent.
2. TRC limit shall take effect July 1, 2006. Limit only applies if chlorine is used for disinfection.
There shall be no discharge of floating solids or foam visible in other than trace amounts.

NPDES Permit Requirements
Page 1 of 16
PART II
STANDARD CONDITIONS FOR NPDES PERMITS
Section A. Definitions
2/Month
Samples are collected twice per month with at least ten calendar days between sampling events.
3/Week
Samples are collected three times per week on three separate calendar days.
Act or "the Act"
The Federal Water Pollution Control Act, also known as the Clean Water Act, as amended, 33 USC 1251, et. seq.
Annual Average
The arithmetic mean. of all "daily discharges"_ of -a pollutant measured during the calendar year. In the case of fecal
coliform, the geometric mean of such discharges.
Arithmetic Mean
The summation of the individual values divided by the number of individual values.
Bypass
The known diversion of waste streams from any portion of a treatment facility including the collection system, which
is not a designed or established or operating mode for the facility.
Calendar Dav
The period from -midnight of one day until midnight of the next day. However, for purposes of this permit, any
consecutive 24-hour period that reasonably represents the calendar day may be used for sampling.
Calendar Quarter
One of the following distinct periods: January through March, April through June, July through September, and
October through December.
Composite Sample
A sample collected over a 24-hour period by continuous sampling or combining grab samples of at least 100 ml in
such a manner as to result in a total sample representative of the wastewater discharge during the sample period. The
Director may designate the most appropriate method (specific number and size of aliquots necessary, the time
interval between grab samples, etc.) on a case -by -case basis. Samples may be collected manually or automatically.
Composite samples may be obtained by the following methods:
(1) Continuous: a single, continuous sample collected over a 24-hour period proportional to the rate of flow.
(2) Constant time/variable volume: a series of grab samples collected at equal time intervals over a 24 hour
period of discharge and combined proportional to the rate of flow measured at the time of individual sample_
collection, or
(3) Variable time/constant volume: a series of grab samples of equal volume collected over a 24 hour period
with the time intervals between samples determined by a preset number of gallons passing the sampling
point. Flow measurement between sample intervals shall be determined by use of a flow recorder and
totalizer, and the preset gallon interval between sample collection fined at no greater than 1/24 of the
expected total daily flow at the treatment system, or
(4) Constant time/constant volume: a series of grab samples of equal volume collected over a 24-hour period at
a constant time interval. This method may only be used in situations where effluent flow rates vary
less than 15 percent. The grab samples - shall be taken at intervals of no greater .than 20 minutes apart
during any 24-hour period and must be of equal size and of no less than 100 milliliters. Use of this method
requires prior approval by the Director.
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NPDES Permit Requirements
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In accordance with (4)-above, influent grab samples shall not be collected more than once per hour.
Effluent grab samples shall not be. collected more than once per hour except at wastewater treatment systems
having a detention time of greater than 24 hours. In such cases, effluent grab samples may be collected at
intervals evenly spaced over the 24-hour period that are equal in number of hours to the detention time of the
system in number of days. However, the interval between effluent grab samples may not exceed six hours nor
the number of samples less than four during a 24-hour sampling period.
Continuous flow measurement
Flow monitoring that occurs without interruption throughout the operating hours of the facility. Flow shall be
monitored continually except for the infrequent times when there may be no flow or for infrequent maintenance
activities on the flow device.
Daily Discharge
The discharge of a pollutant measured during a calendar day or any 24-hour period that reasonably represents the
calendar day for purposes of sampling. For pollutants measured in units of mass, the "daily discharge" is calculated as
the total mass of the pollutant discharged over the day. The "daily discharge" concentration comprises the mean
concentration for a 24-hour sampling period as either a composite sample concentration or the arithmetic mean of all
grab samples collected during that period. (40 CFR 122.3)
Daily Maximum
The highest "daily discharge" during the calendar month.
Daily Sampling
Parameters requiring daily sampling shall be sampled 5 out of every 7 days per week unless otherwise specified in the
permit. The Division expects that sampling shall be conducted on weekdays except where holidays or other
disruptions of normal operations prevent weekday sampling. If sampling is required for all seven days of the week
for any permit parameter(s), that requirement will be so noted on the Effluent Limitations and Monitoring Page(s).
DWQ or "the Division"
The Division of Water Quality, Department of Environment and Natural Resources.
EMC
The North Carolina Environmental Management Commission.
Facility Closure
The cessation of wastewater treatment at a permitted facility, or the cessation of all activities that require coverage
under the NPDES. Completion of facility closure will allow this permit to be rescinded.
Geometric Mean
The Nth root of the product of the individual values where N = the number of individual values. For purposes of
calculating the geometric mean, values of "0" (or "< [detection level]") shall be considered = 1.
Grab Sample
Individual samples of at least 100 ml collected over a period of time not exceeding 15 minutes. Grab samples can be
collected manually. Grab samples must. be representative of the discharge (or the receiving stream, fox 'instream
samples).
Hazardous Substance
Any substance designated under 40 CFR Part 116 pursuant to Section 311 of the Clean Water Act.
Instantaneous flow measurement
A measure of flow taken at the time of sampling, when both the sample and flow will be representative of the total
discharge.
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NPDES Permit Requirements
Page 3 of 16
Monthly Averagg(concentration limit)
The arithmetic mean of all "daily discharges" of a pollutant measured during the calendar month. In the case of fecal
coliform, the geometric mean of such discharges.
Permit Issuing Authority
The Director of the Division of Water Quality.
Quarterly Average (concentration limit)
The average of all samples taken over a calendar quarter.
Severe property damage
Substantial physical damage to property, damage to the treatment facilities which causes them to become inoperable,
or substantial and permanent loss of natural resources which can reasonably be expected to occur in the absence of a
bypass. Severe property damage excludes economic loss caused by delays in production.
Toxic Pollutant:
Any pollutant listed as toxic under Section 307(a)(1) of the Clean Water Act.
Upset
An incident beyond the reasonable control of the Permittee causing unintentional and temporary noncompliance with
permit effluent limitations and/or monitoring requirements. An upset does not include noncompliance caused by
operational error, improperly designed treatment facilities, inadequate treatment facilities, lack of preventive
maintenance, or careless or improper operation.
Weekly Average (concentration lirnit)
The arithmetic mean of all "daily discharges" of a pollutant measured during the calendar week. In. the case of fecal
coliform, the geometric mean of such discharges.
Section B. General Conditions
1. Duty to Comply
The Permittee must comply with all conditions of this permit. Any permit noncompliance constitutes a violation
of the Clean Water Act and is grounds for enforcement action; for permit termination, revocation and reissuance,
or modification; or denial of a permit renewal application [40 CFR 122.41].
a. The Permittee shall comply with effluent standards or prohibitions established under section 307(a) of the
Clean Water Act for toxic pollutants and with standards for sewage sludge use or disposal established under
section 405(d) of the Clean Water Act within the time provided in the regulations that establish these
standards or prohibitions or standards for sewage sludge use or disposal, even if the permit has not yet been
modified to incorporate the requirement.
b. The Clean Water Act provides that any person who violates section 301, 302, 306, 307, 308, 318 or 405 of the
Act, or any permit condition or limitation implementing any such sections in a permit issued under section
402, or any requirement imposed in a pretreatment program approved under sections 402(a)(3) or 402(b)(8)
of the Act, is subject to a civil penalty not to exceed $25,000 per day for each violation. [40 CFR 122.41 (a)
(2)]
c. The Clean Water Act provides that any person who negligentj, violates sections 301, 302, 306, 307, 308, 318, or
405 of the Act, or any condition or limitation implementing any of such sections in a permit issued under
4
j section 402 of the Act, or any requirement imposed in a pretreatment program approved under section
402(a)(3) or 402(b)(8) of the Act, is subject to criminal penalties of $2,500 to $25,000 per day of violation, or
imprisonment of not more than 1 year, or both. In the case of a second or subsequent conviction for a
negligent violation, a person shall be subject to criminal penalties of not more than $50,000 per day 'of
violation, or by imprisonment of not more than 2 years, or both. [40 CFR 122.41 (a) (2)]
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NPDES Permit Requirements -
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d. Any person who kimi ial), violates such sections, or such conditions or limitations is subject to criminal
penalties of $5,000 to $50,000 per day of violation, or imprisonment for not more than 3 years, or both. In
the case of a second or subsequent conviction for a knowing violation, a person shall be subject to criminal
penalties of not more than $100,000 per day of violation, or imprisonment of not more than 6 years, or both.
[40 CFR 122.41 (a) (2)]
e. Any person who knowingly violates section 301, 302, 303, 306, 307, 308, 318 or 405 of the Act, or any permit
condition or limitation implementing any of such sections in a permit issued under section 402 of the Act,
and who knows at that time that he thereby places another person in imminent danger of death or serious
bodily injury, shall; upon conviction, be subject to a foie of not more than $250,000 or imprisonment of not
more than 15 years, or both. In the case of a second or subsequent conviction for a knowing endangerment
violation, a person shall be subject to a fine of not more than $500,000 or by imprisonment of not more than
30 years, or both. An organization, as defined in. section 309(c) (3) (B) (iii) of the CWA, shall, upon conviction
of violating the imminent danger provision, be subject to a fine of not more than $1,000,000 and can be fined
up to $2,000,000 for second or subsequent convictions. [40 CFR 122.41 (a) (2)]
f. Under state law, a civil penalty of not more than $25,000 per violation may be assessed against any person
who violates or fails to act in accordance with the terms, conditions, or requirements of a permit. [North
Carolina General Statutes § 143-215.6A]
g. Any person may be assessed an administrative penalty by the Administrator for violating section 301, 302,
306, 307, 308, 318 or 405 of this Act, or any permit condition or limitation implementing any of such
sections in a permit issued under section 402 of this Act. Administrative penalties for Class I violations are
not to exceed $10,000 per violation, with the maximum amount of any Class I penalty assessed not to exceed
$25,000. Penalties for Class II violations are not to exceed $10,000 per day for each day during which the
violation continues, with the maximum amount of any Class II penalty not to exceed $125,000. [40 CFR
122.41 (a) (3)]
2. Duty to Mitigate
The Permittee shall take all reasonable steps to minimize or prevent any discharge or sludge use or disposal in
violation of this permit which has a reasonable likelihood of adversely affecting human health or the environment
[40 CFR 122.41 (d)].
3. Civil and Criminal Liability
Except as provided in permit conditions on "Bypassing" (Part II. C. 4), "Upsets" (Part II. C. 5) and "Power
Failures" (Part II. C. 7), nothing in this permit shall be construed to relieve the Permittee from any
responsibilities, liabilities, or penalties for noncompliance pursuant to NCGS 143-215.3, 143-215.6 or Section 309
of the Federal Act, 33 USC 1319. Furthermore, the Permittee is responsible for consequential damages, such as
fish kills, even though the responsibility for effective compliance may be temporarily suspended.
4. Oil and Hazardous Substance Liability
Nothing in this permit shall be construed to preclude the institution of any legal action or relieve the Permittee
from any responsibilities, liabilities, or penalties to which the Permittee is or may be subject to under NCGS 143-
215.75 et seq. or Section 311 of the Federal Act, 33 USG 1321. Furthermore, the Permittee is responsible for
consequential damages, such as fish kills, even though the responsibility for effective compliance may be
temporarily suspended.
5. Property Rights
The issuance of this permit does not convey any property rights in either real or personal property, or any
exclusive privileges, nor does it authorize any injury to private property or any invasion of personal rights, nor
any infringement of Federal, State or local laws or regulations [40 CFR 122.41 (g)].
6. Onshore or Offshore Construction
This permit does not authorize or approve the construction of any onshore or offshore physical structures or
facilities or the undertaking of any work in any navigable waters.
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NPDES Permit Requirements
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7. Severability
The provisions of this permit are severable. If any provision of this permit, or the application of any provision of this
permit to any circumstances, is held invalid, the application of such provision to other circumstances, and the remainder
of this permit, shall not be affected thereby [NCGS 150B-23].
8. Duty to Provide Information
The Permittee shall furnish to the Permit Issuing Authority, within a reasonable time, any information which the
Permit Issuing Authority may request to determine whether cause exists for modifying, revoking and reissuing, or
terminating this permit or to determine compliance with this permit. The Permittee shall also furnish to the
Permit Issuing Authority upon request, copies of records required by this permit [40 CFR 122.41 (h)].
9. Duty to Reapply
If the Permittee wishes to continue an activity regulated by this permit after the expiration date of this permit, the
Permittee must apply for and obtain a new permit [40 CFR 122.41 (b)].
10. Expiration of Permit
The Permittee is not authorized to discharge after the expiration date. In order to receive automatic
authorization to discharge beyond the expiration date, the Permittee shall submit such information, forms, and
fees as are required by the agency authorized to issue permits no later than 180 days prior to the expiration date.
Any Permittee that has not requested renewal at least 180 days prior to expiration, or any Permittee that does not
have a permit after the expiration and has not requested renewal at least 180 days prior to expiration, will subject
the Permittee to enforcement procedures as provided in NCGS 143-215.6 and 33 USC 1251 et. seq.
11. Si iatory Requirements
All applications, reports, or information submitted to the Permit Issuing Authority shall be signed and certified
[40 CFR 122.41 (k)].
a. All permit applications shall be signed as follows:
(1) For a corporation: by a responsible corporate officer. For the purpose of this Section, a responsible
corporate officer means: (a) a president, secretary, treasurer or vice president of the corporation in
charge of a principal business function, or any other person who performs similar policy or decision
making functions for the corporation, or (b) the manager of one or more manufacturing, production, or
operating facilities, provided, the manager is authorized to make management decisions which govern the
operation of the regulated facility including having the explicit or implicit duty of making major capital
investment recommendations, and initiating and directing other comprehensive measures to assure long
term environmental compliance with environmental laws and regulations; the manager can ensure that
the necessary systems are established or actions taken to gather complete and accurate information for
permit application requirements; and where authority to sign documents has been assigned or delegated
to the manager.in accordance with corporate procedures .
(2) For a partnership or sole proprietorship: by a general partner or the proprietor, respectively; or
(3) For a municipality, State, Federal, or other public agency: by either a principal executive officer or
ranking elected official [40 CFR 122.22].
b. All reports required by the permit and other information requested by the Permit Issuing Authority shall be
signed by a person described in paragraph a. above or by a duly authorized representative of that person. A
person is a duly authorized representative only if:
1. The authorization is made in writing by a person described above;
2. The authorization specified either an individual or a position having responsibility for the overall
operation of the regulated facility or activity, such as the position of plant manager, operator of a well or
well field, superintendent, a position of equivalent responsibility, or an individual or position having
overall responsibility for environmental matters for the company. (A duly authorized representative may
thus be either a named individual or any individual occupying a named position.); and
3. The written authorization is submitted to the Permit Issuing Authority [40 CFR 122.22]
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NPDES Permit Requirements
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c. Changes to authorization: If an authorization under paragraph (b) of this section is no longer accurate
because a different individual or position has responsibility for the overall operation of the facility, a new
authorization satisfying the requirements of paragraph (b) of this section must be submitted to the Director
prior to or together with any reports, information, or applications to be signed by an authorized
representative [40 CFR 122.22]
d. Certification. Any person signing 'a document under paragraphs a. or b. of this section shall make the
following certification [40 CFR 122.22]:
"1 certify, under penalty of law, that this document and all attachments were prepared under my direction or
supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate
the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons
directly responsible for gathering the information, the information submitted is, to the best of my knowledge and
belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information,
including the possibility of fines and imprisonment for knowing violations."
12. Permit Actions
This permit may be modified, revoked and reissued, or terminated for cause. The filing of a request by the
Permittee for a permit modification, revocation and reissuance, or termination, or a notification of planned
changes or anticipated noncompliance does not stay any permit condition [40 CFR 122.41 (Q.
13. Permit Modification. Revocation and Reissuance or Termination
The issuance of this permit does not prohibit the permit issuing authority from reopening and modifying the
permit, revoking and reissuing the permit, or terminating the permit as allowed by the laws, rules, and regulations
contained in Title 40, Code of Federal Regulations, Parts 122 and 123; Title 15A of the North Carolina
Administrative Code, Subchapter 2H .0100; and North Carolina General Statute 143-215.1 et. al.
14. Annual Administering and Compliance Monitoring Fee Requirements
The Permittee must pay the annual administering and compliance monitoring fee within thirty days after being
billed by the Division. Failure to pay the fee in a timely manner in accordance with 15A &CAC 2H.0105 (b) (4)
may cause this Division to initiate action to revoke the permit.
Section C. Operation and Maintenance of Pollution Controls
Certified Operator
Upon classification of the permitted facility by the Certification Commission, the Permittee shall employ a
certified water pollution control treatment system operator in responsible charge (ORC) of the water pollution
control treatment system. Such operator must hold a certification of the grade equivalent to or greater than the
classification assigned to the water pollution control treatment system by the Certification Commission. The
Permittee must also employ one or more certified Back-up ORCs who possess a currently valid certificate of the
type of the system. Back-up ORCs must possess a grade equal to (or no more than one grade less than) the grade
of the system [15A NCAC 8G.0201].
The ORC of each Class I facility must:
➢ Visit the facility at least weekly
➢ Comply with all other conditions of 15A NCAC 8G.0204.
The ORC of each Class II, III and IV facility must: .
➢ Visit the facility at least daily, excluding weekends and holidays
➢ Properly manage and document daily operation and maintenance of the facility
➢ Comply with all other conditions of 15A NCAC 8G.0204.
Once the facility is classified, the Permittee shall submit a letter to the Certification Commission designating the
operator in responsible charge:
a. Within 60 calendar days prior to wastewater being introduced into a new system
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b. Within 120 calendar days of:
➢ Receiving notification of a change in the classification of the system requiring the designation of a
new.ORC and back-up ORC
➢ A vacancy in the position of ORC or back-up ORC.
2. Proper Operation and Maintenance
The Permittee shall at all times provide the operation and maintenance resources necessary to operate the existing
facilities at optimum efficiency. The Permittee shall at all times properly operate and maintain all facilities and
systems of treatment and control (and related appurtenances) which are installed or used by the Permittee to
achieve compliance with the conditions of this permit. Proper operation and maintenance also includes adequate
laboratory controls and appropriate quality assurance procedures. This provision requires the Permittee to install
and operate backup or auxiliary facilities only when necessary to achieve compliance with the conditions of the
permit [40 CFR 122.41 (e)].
3. Need to Halt or Reduce not a Defense
It shall not be a defense for a Permittee in an enforcement action that it would have been necessary to halt or
reduce the permitted activity in order to maintain compliance with the condition of this permit [40 CFR 122.41
(CA.
4. Bypassing of Treatment Facilities
a. Bypass not exceeding limitations [40 CFR 122.41 (m) (2)]
The Permittee may allow any bypass to occur which does not cause effluent limitations to be exceeded, but
only if it also is for essential maintenance to assure efficient operation. These bypasses are not subject to the
provisions of Paragraphs b. and c. of this section.
b. Notice [40 CFR 122.41 (m) (3)]
(1) Anticipated bypass. If the Permittee knows in advance of the need for a bypass, it shall submit prior
notice, if possible at least ten days before the date of the bypass; including an evaluation of the
anticipated quality and effect of the bypass.
(2) Unanticipated bypass. The Permittee shall submit notice of an unanticipated bypass as required in Part
II. E. 6. (24-hour notice).
c. Prohibition of Bypass
(1) Bypass from the treatment facility is prohibited and the Permit Issuing Authority may take enforcement
action against a Permittee for bypass, unless:
(A) Bypass was unavoidable to prevent loss of life, personal injury or severe property damage;
(B) There were no feasible alternatives to the bypass, such as the use of auxiliary treatment facilities,
retention of untreated wastes or maintenance during normal periods of equipment downtime. This
condition is not satisfied if adequate backup equipment should have been installed in the exercise of
reasonable engineering judgment to prevent a bypass which occurred during normal periods of
equipment downtime or preventive maintenance; and
(C) The Permittee submitted notices as required under Paragraph b. of this section.
(2) Bypass from the collection system is prohibited and the Permit Issuing Authority may take enforcement
action against a Permittee for a bypass as provided in any current or future system -wide collection system
permit associated with the treatment facility.
(3) The Permit Issuing Authority may approve an anticipated bypass, after considering its adverse effects, if
the Permit Issuing Authority determines that it will meet the three conditions listed above in Paragraph c.
(1) of this section.
5. U sets
a. Effect of an upset [40 CFR 122.41 (n) (2)1: An upset constitutes an affirmative defense to an action
brought for noncompliance with such technology based permit effluent limitations if the requirements of
paragraph b. of this condition are met. No determination made during administrative review of claims that
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noncompliance was caused by upset, and before an action'for noncompliance, is final administrative action
subject to judicial review.
b. Conditions necessary for a demonstration of upset: A Permittee who wishes to establish the
affirmative defense of upset shall demonstrate, through properly signed, contemporaneous_ operating logs, or
other relevant evidence that:
(1) An upset occurred and that the Permittee can identify the cause(s) of the upset;
(2) The Permittee facility was at the time being properly operated; and
(3) The Permittee submitted notice of the upset as required in Part II. E. 6. (b) (B) of this permit.
(4) The Permittee complied with any remedial measures required under Part II. B. 2. of this permit.
d. Burden of proof [40 CFR 122.41 (n) (4)]: The Permittee seeking to establish the occurrence of an
upset has the burden of proof in any enforcement proceeding.
6. Removed Substances
Solids, sludges, filter backwash, or other pollutants removed in the course of treatment or control of wastewaters
shall be utilized/disposed of in accordance with NCGS 143-215.1 and in a manner such as to prevent any pollutant
from such materials from entering waters of the State or navigable waters of the United States. The Permittee
shall comply with all existing Federal regulations governing the disposal of sewage sludge. Upon promulgation of
40 CFR Part 503, any permit issued by the Permit Issuing Authority for the utilization/disposal of sludge may be
reopened and modified, or revoked and reissued, to incorporate applicable requirements at 40 CFR 503. The
Permittee shall comply with applicable 40 CFR 503 Standards for the Use and Disposal of Sewage Sludge (when
promulgated) within the time provided in the regulation, even if the permit is not modified to incorporate the
requirement. The Permittee shall notify the Permit Issuing Authority of any significant change in its sludge use
or disposal practices.
7. Power Failures
The Permittee is responsible for maintaining adequate safeguards (as required by 15A NCAC 211.0124 —
Reliability) to prevent the discharge of untreated or inadequately treated wastes during electrical power failures
either by means of alternate power sources, standby generators or retention of inadequately treated effluent.
i
Section D. Monitoring and Records
1. Representative Sampling
Samples collected and measurements taken, as required herein, shall be characteristic of the volume and nature of
the permitted discharge. Samples collected at a frequency less than daily shall be taken on a day and time that is
characteristic of the discharge over the entire period the sample represents. All samples shall be taken at the
monitoring points specified in this permit and, unless otherwise specified, before the effluent joins or is diluted
by any other wastestream, body of water, or substance. Monitoring points shall not be changed without
notification to and the approval of the Permit Issuing Authority [40 CFR 122.41 (j)].
2. Reporting
Monitoring results obtained during the previous month(s) shall be summarized for each month and reported on a
monthly Discharge Monitoring Report (DMR) Form (MR 1, 1.1, 2, 3) or alternative forms approved by the
Director, postmarked no later than the 28th day following the completed reporting period.
The first DMR is due on the last day of die month following the issuance of the permit or in the case of a new
facility, on the last day of the month following die commencement of discharge. Duplicate signed copies of
these, and all other reports required herein, shall be submitted to the following address:
NC DENR / Division of Water .Quality / Water Quality Section
ATTENTION: Central Files
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
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Flow Measurements
Appropriate flow measurement devices and methods consistent with accepted scientific practices shall be selected
and used to ensure the accuracy and reliability of measurements of the volume of monitored discharges. The
devices shall be installed, calibrated and maintained to ensure that the accuracy of the measurements is consistent
with the accepted capability of that type of device. Devices selected shall be capable of measuring flows with a
maximum deviation of less than 10% from the true discharge rates throughout the range of expected discharge
volumes. Flow measurement devices shall be accurately calibrated at a minimum of once per year and maintained
to ensure that the accuracy of the measurements is consistent with the accepted capability of that type of device.
The Director shall approve the flow measurement device and monitoring location prior to installation.
Once -through condenser cooling water flow monitored by pump logs, or pump hour meters as specified in Part I
of this permit and based on the manufacturer's pump curves shall not be subject to this requirement.
4. Test Procedures
Test procedures for the analysis of pollutants shall conform to the EMC regulations (published pursuant to
NCGS 143-215.63 et. seq.), the Water and Air Quality Reporting Acts, and to regulations published pursuant to
Section 304(g), 33 USC 1314, of the Federal Water Pollution Control Act (as Amended), and 40 CFR 136; or in
the case of sludge use or disposal, approved under 40 CFR 136, unless otherwise specified in 40 CFR 503, unless
other test procedures have been specified in this permit [40 CFR 122.41].
To meet the intent of the monitoring required by this permit, all test procedures must produce minimum
detection and reporting levels that are below the permit discharge requirements and all data generated must be
reported down to the minimum detection or lower reporting level of the procedure. If no approved methods are
determined capable of achieving minimum detection and reporting levels below permit discharge requirements,
then the most sensitive (method with the lowest possible detection and reporting level) approved method must
be used.
5. Penalties for Tampering
The Clean Water Act provides that any person who falsifies, tampers with, or knowingly renders inaccurate, any
monitoring device or method required to be maintained under this permit shall, upon conviction, be punished by
a fine of not more than $10,000 per violation, or by imprisonment for not more than two years per violation, or
by both. If a conviction of a person is for a violation committed after a first conviction of such person under this
paragraph, punishment is a fine of not more than $20,000 per day of violation, or by imprisonment of not more
than 4 years, or both [40 CFR 122.41].
6. Records Retention
Except for records of monitoring information required by this permit related to the Permittee's sewage sludge
use and disposal activities, which shall be .retained for a period of at least five years (or longer as required by 40
CFR 503), the Permittee shall retain records of all monitoring information, including:
➢ all calibration and maintenance records
➢ all original strip chart recordings for continuous monitoring instrumentation
➢ copies of all reports required by this permit
➢ copies of all data used to complete the application for this permit
These records or copies shall be maintained for a period of at least 3 years from the date of the sample,
measurement, report or application. This period may be extended by request of the Director at any time [40 CFR
122.41].
7. Recording Results
For each measurement or sample taken pursuant to the requirements of this permit, the Permittee shall record
the following information [40 CFR 122.41]:
a. The date, exact place, and time of sampling or measurements;
b. The individual(s) who performed the sampling or measurements;
c. The date(s) analyses were performed;
d. The individual(s) who performed the analyses;
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e. The analytical techniques or methods used; and
f. The results of such analyses.
8. Inspection and Entnc�
The Permittee shall allow the Director, or an authorized representative (including an authorized contractor acting
as a representative of the Director), upon the presentation of credentials and other documents as may be required
by law, to;
a. Enter upon the Permittee's premises where a regulated facility or activity is located or conducted, or where
records must be kept under the conditions of this permit;
b. Have access to and copy, at reasonable times, any records that must be kept under the conditions of this
permit;
c. Inspect at reasonable times any facilities, equipment (including monitoring and control equipment), practices,
or operations regulated or required under this permit; and
d. Sample or monitor at reasonable times, for the purposes of assuring permit compliance or as otherwise
authorized by the Clean Water Act, any substances or parameters at any location [40 CFR 122.41 (i)].
Section E Reporting Requirements
1. Change in Discharge
All discharges authorized herein shall be consistent with the terms and conditions of this permit. The discharge
of any pollutant identified in this permit more frequently than or at a level in excess of that authorized shall
constitute a violation of the permit.
2. Planned Changes
The Permittee shall give notice to die Director as
additions to the permitted facility [40 CFR 122.41 (1)].
soon as possible of any planned physical alterations or
Notice is required only when:
a. The alteration or addition to a permitted facility may meet one of the criteria for new sources at 40 CFR
122.29 (b); or
b. The alteration or addition could significantly change the nature or increase the quantity of pollutants
discharged. This notification applies to pollutants subject neither to effluent limitations in the permit, not to
notification requirements under 40 CFR 122.42 (a) (1).
c. The alteration or addition results in a significant change in the Permittee's sludge use or disposal practices,
and such alternation, addition or change may justify the application of permit conditions that are different
from or absent in the existing permit, including notification of additional use or disposal sites not reported
during the permit application process or not reported pursuant to an approved land application plan.
3. Anticipated Noncompliance
The Permittee shall give advance notice to the Director of any planned changes to the permitted facility or other
activities that might result in noncompliance with the permit [40 CFR 122.41 (1) (2)].
4. Transfers
This permit is not transferable to any person except after notice to the Director. The Director may require
modification or revocation and reissuance of tie permit to document the change of ownership. Any such action
may incorporate other requirements as may be necessary under the'Clean Water Act [40 CFR 122.41 (1) (3)].
S. Monitoring Reports
Monitoring results shall be reported at the intervals specified elsewhere in this permit [40 CFR 122.410) (4)].
a. Monitoring results must be reported on a Discharge Monitoring Report (DMR) (See Part II. D. 2) or forms
provided by the Director for reporting results of monitoring of sludge use or disposal practices.
b. If the Permittee monitors any pollutant more frequently than required by this permit, the results of such
monitoring shall be included in the calculation and reporting of the data submitted on the DMR.
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6. Twenty-four Hour Reporting
a. The Permittee shall report to the Director or the appropriate Regional Office any noncompliance that
potentially threatens public health or the environment. Any information shall be provided orally within 24
hours from the time the Permittee became aware of the circumstances. A written submission shall also be
provided within 5 days of the time the Permittee becomes aware of the circumstances. The written
submission shall contain a description of the noncompliance, and its cause; the period of noncompliance,
including exact dates and times, and if the noncompliance has not been corrected, the anticipated time it is
expected to continue; and steps taken or planned to reduce, eliminate, and prevent reoccurrence of the
noncompliance [40 CFR 122.41 (1) (6)].
b. The Director may waive the written report on a case -by -case basis for reports under this section if the oral
report has been received within 24 hours.
c. Occurrences outside normal business hours may also be reported to the Division's Emergency Response
personnel at [phone], [phone] or [phone].
7. Other Noncompliance
The Permittee shall report all instances of noncompliance not reported under Part II. E. 5 and 6. of this permit at
the time monitoring reports are submitted. The reports shall contain the information listed in Part II. E. 6. of
this permit [40 CFR 122.41 (1) (7)].
8. Other Information
Where the Permittee becomes aware that it failed to submit any relevant facts in a permit application, or
submitted incorrect information in a permit application or in any report to the Director, it shall promptly submit
such facts or information [40 CFR 122.41 (1) (8)].
Noncompliance Notification
The Permittee shall report by telephone to either the central office or the appropriate regional office of the
Division as soon as possible, but in no case more than 24 hours or on the next working day following the
occurrence or first knowledge of the occurrence of any of the following:
a. Any occurrence at the water pollution control facility which results in the discharge of significant amounts of
wastes which are abnormal in quantity or characteristic, such as the dumping of the contents of a sludge
digester; the known passage of a slug of hazardous substance through the facility; or any other unusual
circumstances.
b. Any process unit failure, due to known or unknown reasons, that render the facility incapable of adequate
wastewater treatment such as mechanical or electrical failures of pumps, aerators, compressors, etc.
c. Any failure of a pumping station, sewer line, or treatment facility resulting in a by-pass directly to receiving
waters without treatment of all or any portion of the influent to such station or facility.
Persons reporting such occurrences by telephone shall also file a written report within 5 days following first
knowledge of the occurrence.
10. Availability of Reports
Except for data determined to be confidential under NCGS 143-215.3 (a)(2) or Section 308 of'the Federal Act, 33
USC 1318, all reports prepared in accordance with the terms shall be available for public inspection at the offices
of the Division of Water Quality. As required by the Act, effluent data shall not be considered confidential.
Knowingly making any false statement on any such report may result in the imposition of criminal penalties as
provided for in NCGS 143-215.1 (b)(2) or in Section 309 of the Federal Act.
11. Penalties for Falsification of Reports
The Clean Water Act provides that any person who knowingly makes any false statement, representation, or
certification in any record or other document submitted or required to be maintained under this permit, including
monitoring reports or reports of compliance or noncompliance shall, upon conviction, be punished by a fine of
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not more than $25,000 per violation, or by imprisonment for not more than two years per violation, or by both
[40 CFR 122.41].
12. Annual Performance Reports
Permittees who own or operate facilities that collect or treat municipal or domestic waste shall provide an annual
report to the Permit Issuing Authority and to the users/customers served by the Permittee (NCGS 143-215.1C).
The report shall summarize the performance of the collection or treatment system, as well as the extent to which
the facility was compliant with applicable Federal or State laws, regulations and rules pertaining to water quality.
The report shall be provided no later than sixty days after the end of the calendar or fiscal year, depending upon
which annual period is used for evaluation.
PART III
OTHER REQUIREMENTS
Section A. Construction
The Permittee shall not commence construction of wastewater treatment facilities, nor add to the plant's treatment
capacity, nor change the treatment process(es) utilized at the treatment plant unless the Division has issued an
Authorization to Construct (AtC) permit. Issuance of an AtC will not occur until Final Plans and Specifications for
the proposed construction have been submitted by the Permittee and approved by the Division.
Section B. Groundwater Monitorin
The Permittee shall, upon written notice from the Director of the Division of Water Quality, conduct groundwater
monitoring as may be required to determine the compliance of this NPDES permitted facility with the current
groundwater standards. .
Section C. Changes in Discharges of Toxic Substances
The Permittee shall notify the Permit Issuing Authority as soon as it knows or has reason to believe (40 CFR 122.42):
a. That any activity has occurred or will occur which would result in the discharge, on a routine or frequent
basis, of any toxic pollutant which is not limited in the permit, if that discharge will exceed the highest of the
following "notification levels";
0) One hundred micrograms per liter (100 µg/L);
(2) Two hundred micrograms per liter (200 µg/L) for acrolein and acrylonitrile; five hundred micrograms
per liter (500 µg/L) for 2.4-dinitrophenol and for 2-methyl-4.6-dinitrophenol; and one milligram per liter
0 mg/L) for antimony;
(3) Five times the maximum concentration value reported for that pollutant in the permit application.
b. That any activity has occurred or will occur which would result in any discharge, on a non -routine or
infrequent basis, of a toxic pollutant which is not limited in the permit, if that discharge will exceed the
highest of the following "notification levels';
(1) Five hundred micrograms per liter (500 µg/L);
(2) One milligram per liter (1 mg/L) for antimony;
(3) Ten times the maximum concentration value reported for that pollutant in the permit application.
Section D. Evaluation of Wastewater Discharge Alternatives
The Permittee shall evaluate all wastewater disposal alternatives and pursue the most environmentally sound
alternative of the reasonably cost effective alternatives. If the facility is in substantial non-compliance with the terms
and conditions of the NPDES permit or governing rules, regulations or laws, the Permittee shall submit a report in
such form and detail as required by the Division evaluating these alternatives and a plan of action within 60 days of
notification by the Division.
Section E. Facility Closure Requirements
The Permittee must notify the Division at least 90 days prior to the closure of any wastewater treatment system
covered by this permit. The Division may require specific measures during deactivation of the system to prevent
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adverse impacts to waters of the State. This permit cannot be rescinded while any activities requiring this permit
continue at the permitted facility.
PART IV
SPECIAL CONDITIONS FOR MUNCIPAL FACILITIES
Section A. Publicly Owned Treatment Works (POTWs�
All POTWs must provide adequate notice to the Director of the following:
1. Any new introduction of pollutants into the POTW from an indirect discharger which would be subject to
section 301 or.306 of CWA if it were directly discharging those pollutants; and
2. Any substantial change in the volume or character of pollutants being introduced by an indirect discharger
as influent to that POTW at the time of issuance of the permit.
3. For purposes of this paragraph, adequate notice shall include information on (1) the quality and quantity of
effluent introduced into the POTW, and (2) any anticipated impact of the change on the quantity or quality
of effluent to be -discharged from the POTW.
Section B. Municipal Control of Pollutants from Industrial Users.
Effluent limitations are listed in Part I of this permit. Other pollutants attributable to inputs from
industries using the municipal system may be present in the Permittee's discharge. At such time as
sufficient information becomes available to establish limitations for such pollutants, this permit may be
revised to specify effluent limitations for any or all of such other pollutants in accordance with best
practicable technology or water quality standards.
2. Under no circumstances shall the Permittee allow introduction of the following wastes in the waste
treatment system:
a. Pollutants which create a fire or explosion hazard in the POTW, including, but not limited to,
wastestreams with a closed cup flashpoint of less than 140 degrees Fahrenheit or 60 degrees
Centigrade using the test methods specified in 40 CFR 261.21;
b. Pollutants which will cause corrosive structural damage to the POTW, but in no case Discharges
with pH lower than 5.0, unless the works is specifically designed to accommodate such Discharges;
C. Solid or viscous pollutants in amounts which will cause obstruction to the flow in the POTW
resulting in Interference;
d. Any pollutant, including oxygen demanding pollutants (BOD, etc.) released in a Discharge at a flow
rate and/or pollutant concentration which will cause Interference with the POTW;
e. Heat in amounts which will inhibit biological activity in the POTW resulting in Interference, but in
no case heat in such quantities that the temperature at the POTW Treatment Plant exceeds 40°C
(104°F) unless the Division, upon request of the POTW, approves alternate temperature limits;
f. Petroleum oil, nonbiodegradable cutting oil, or products of mineral oil origin in amounts that will
cause interference or pass through;
g. Pollutants which result in the presence of toxic gases, vapors, or hones within the POTW in a
quantity that may cause acute worker health and safety problems;
h. Any trucked or hauled pollutants, except at discharge points designated by the POTW.
3. -With regard to the effluent requirements listed in Part I of this permit, it may be necessary for the
Permittee to supplement the requirements of the Federal Pretreatment Standards (40 CFR, Part 403) to
ensure compliance by the Permittee with all applicable effluent limitations. Such actions by the Permittee
may be necessary regarding some or all of the industries discharging to the municipal system.
4. The Permittee shall require any industrial discharges sending influent to the permitted system to meet
Federal Pretreatment Standards promulgated in response to Section 307(b) of the Act. Prior to accepting
wastewater from any significant industrial user, the Permittee shall either develop and submit to the
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Division a Pretreatment Program for approval per 15A NCAC 2H .0907(a) .or modify an existing
Pretreatment Program per 15A NCAC 2H .0907(b).
5. This permit shall be modified, or alternatively, revoked and reissued, to incorporate or modify an approved
POTW Pretreatment Program or to include a compliance schedule for the development of a POTW
Pretreatment Program as required under Section 402(b)(8) of the Clean Water Act and implementing
regulations or by the requirements of the approved State pretreatment program, as appropriate.
Section C. Pretreatment Programs
Under authority of sections 307(b) and (c) and 402(b)(8) of the Clean Water Act and implementing regulations 40
CFR Part 403, North Carolina General Statute 143-215.3 (14) and implementing regulations 15A NCAC 2H
.0900, and in accordance with the approved pretreatment program, all provisions and regulations contained and
referenced in the Pretreatment Program Submittal are an enforceable part of this permit.
The Permittee shall operate its approved pretreatment program in accordance with Section 402(b)(8) of the Clean
Water Act, the Federal Pretreatment Regulations 40 CFR Part 403, the State Pretreatment Regulations 15A
NCAC 2H .0900, and the legal authorities, policies, procedures, and financial provisions contained in its
pretreatment program submission and Division approved modifications there of. Such operation shall include
but is not limited to the implementation of the following conditions and requirements:
1. Sewer Use Ordinance (SUO)
The Permittee shall maintain adequate legal authority to implement its approved pretreatment program.
2. Industrial Waste Survey (IWS)
The Permittee shall update its Industrial Waste Survey (IWS) to include all users of the sewer collection
system at least once every five years.
Monitoring Plan
The Permittee shall implement a Division approved Monitoring Plan for the collection of facility specific
data to be used in a wastewater treatment plant Headworks Analysis (HWA) for the development of
specific pretreatment local limits. Effluent data from the Plan shall be reported on the DMRs (as required
by Part II, Section D, and Section E.5.).
4. Headworks Analysis Ai and Local Limits
The Permittee shall obtain Division approval of a Headworks Analysis (HWA) at least once every five
years, and as required by the Division. Within 180 'days of the effective date of this permit (or any
subsequent permit modification) the Permittee shall submit to the Division a written technical evaluation
of the need to revise local limits (i.e., an updated HWA or documentation of why one is not needed) [40
CFR 122.42]. The Permittee shall develop, in accordance with 40 CFR 403.5(c) and 15A NCAC 2H .0909,
specific Local Limits to implement the prohibitions listed in 40 CFR 403.5(a) and (b) and 15A NCAC 2H
.0909.
5. Industrial User Pretreatment Permits (ILM & Allocation Tables
In accordance with NCGS 143-215.1, the Permittee shall issue to all significant industrial users, permits for
operation of pretreatment equipment and discharge to the Permittee's treatment works. These permits
shall contain limitations, sampling protocols, reporting requirements, appropriate standard and special
conditions, and compliance schedules as necessary for the installation of treatment and control
technologies to assure that their wastewater discharge will meet all applicable pretreatment standards and
requirements. The Permittee shall maintain a current Allocation Table (AT) which summarizes the results
of the Headworks Analysis (HWA) and the limits from all Industrial User Pretreatment Permits (IUP).
Permitted IUP loadings for each parameter cannot exceed the treatment capacity of the POTW as
determined by the HWA.
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6. Authorization to Construct (A to C)
The Permittee shall ensure that an Authorization to Construct permit (AtC) is issued to all applicable
industrial users for the construction or modification of any pretreatment facility. Prior to the issuance of
an AtC, the proposed pretreatment facility and treatment process must be evaluated for its capacity to
comply with all Industrial User Pretreatment Permit (IUP) limitations.
POTW Inspection & Monitoring of their SIUs
The Permittee shall conduct inspection, surveillance, and monitoring activities as described in its Division
approved pretreatment program in order to determine, independent of information supplied by industrial
users, compliance with applicable pretreatment standards. The Permittee must:
a. Inspect all Significant Industrial Users (SIUs) at least once per calendar year; and
b. Sample all Significant Industrial Users (SIUs) at least twice per calendar year for all permit -
limited pollutants, once during the period from January 1 through June 30 and once during the
period from July 1 through December 31, except for organic compounds which shall be sampled
once per calendar year;
8. SIU Self Monitoring and Reporting
The Permittee shall require all industrial users to comply with the applicable monitoring and reporting
requirements outlined in the Division approved pretreatment program, the industry's pretreatment permit,
or in 15A NCAC 2H .0908.
Enforcement Response Plan (ERP)
The Permittee shall enforce and obtain appropriate remedies for violations of all pretreatment standards
promulgated pursuant to section 307(b) and (c) of the Clean Water Act (40 CFR 405 et. seq.), prohibitive
discharge standards as set forth in 40 CFR 403.5 and 15A NCAC 2H .0909, and specific local limitations.
All enforcement actions shall be consistent with the Enforcement Response Plan (ERP) approved by the
Division.
10. Pretreatment Annual Reports W=
The Permittee shall report to the Division in accordance with 15A NCAC 2H .0908. In lieu of submitting
annual reports, Modified Pretreatment Programs developed under 15A NCAC 2H .0904 (b) may be
required to meet with Division personnel periodically to discuss enforcement of pretreatment requirements
and other pretreatment implementation issues.
For all other active pretreatment programs, the Permittee shall submit two copies of a Pretreatment Annual
Report (PAR) describing its pretreatment activities over the previous twelve months to the Division at the
following address:
NC DENR / DWQ / Pretreatment Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
These reports shall be submitted according to a schedule established by the Director and shall contain the
following:
a.) Narrative
A brief discussion of reasons for, status of, and actions taken for all Significant Industrial
Users (SIUs) in Significant Non -Compliance (SNC);
b.) Pretreatment Program Summary(PPS)
A pretreatment program summary (PPS) on specific forms approved by the Division;
c.) Significant Non -Compliance Report (SNCR)
The nature of the violations and the actions taken or proposed to correct the violations on
specific forms approved by the Division;
d.) Industrial Data Summary Forms (IDSF)
Version 6/20/2003

NPDES Permit R,.quirements
Page 16-of 16
Monitoring data from samples collected by both the POTW and the Significant Industrial
User (SIU). These analytical results must be reported on Industrial Data Sutnmaiy Forms
(IDSF) or other specific format approved by the Division;
e.) Other Information
Copies of the POTW s allocation table, new or modified enforcement compliance schedules,
public notice of SIUs in SNC, and any other information, upon request, which in the
opinion of the Director is needed to determine compliance with the pretreatment
implementation requirements of this permit;
11. Public Notice
The Permittee shall publish annually a list of Significant Industrial Users (SIUs) that were in Significant
Non -Compliance (SNC) as defined in the Permittee's Division approved Sewer Use Ordinance with
applicable pretreatment requirements and standards during the previous twelve month period. This list
shall be published within four months of the applicable twelve-month period.
12. Record Keeping
The Permittee shall retain for a minimum of three years records of monitoring activities and results, along
with support information including general records, water quality records, and records of industrial impact
on the POTW.
13. Funding and Financial Report
The Permittee shall maintain adequate funding and staffing levels to accomplish the objectives of its
approved pretreatment program.
14. Modification to Pretreatment Programs
Modifications to the approved pretreatment program including but not limited to local limits
modifications, POTW monitoring of their Significant Industrial Users (SIUs), and Monitoring Plan
modifications, shall be considered a permit modification and shall be governed by 15 NCAC 2H .0114 and
15A NCAC 2H .0907.
Version 612012003

Ms. Pamela Edwards Ford
Hill Haven Residential Care, Inc..
142 Oak Haven Drive
Statesville, North Carolina 28625
SUBJECT:
Dear Ms. Ford:
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
March 22, 2006
Authorization to Col o `NIJwx
A to C No. 045012AOI
Hill Haven Residential Care, Inc.
Hill Haven Residential Care, Inc. WWTP
Iredell County
A fast track application for Authorization to Construct dechlorination facilities was
received on March 21, 2006, by the Division. Authorization is hereby granted for the
construction of modifications to the existing Hill Haven Residential Care, Inc. WWTP, with
discharge of treated wastewater into Third Creek in the Yadkin -Pee Dee River Basin.
This authorization results in no increase in design or permitted capacity and is awarded
for the construction of the following specific modifications:
Installation of a sodium sulfite tablet dechlorination system, pursuant to the fast
track application received on March 21, 2006, and in conformity with the
Minimum Design Criteria for Dechlorination Facilities.
This Authorization to Construct is issued in accordance with Part In, -Paragraph A of
NPDES Permit No. NCO045012 issued May 1, 2005, and shall be subject to revocation unless
the wastewater treatment facilities are constructed in accordance with the conditions and
limitations specified in Permit No. NC0045012.
In the event that the facilities fail to perform satisfactorily, including the creation of
nuisance conditions, the Permittee shall take immediate corrective action, including those as may
be required by this Division, such as the construction of additional or replacement wastewater
treatment or disposal facilities.
The Mooresville Regional Office, telephone number [phone], shall be notified at
least forty-eight (48) hours in advance of operation of the installed facilities so that an on site
NorthCarolina
AR11rallil
North Carolina Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 Phone [phone] Customer Service
Internet: h2o.enr.state.nc.us 512 N. Salisbury St. Raleigh, NC 27604 FAX [phone]-623'-6748
An Equal Opportunity/Affirmative Action Employer — 50% Recycled110% Post Consumer Paper

Ms. Pamela Edwards Ford
March 22, 2006
Page 2
inspection can be made. Such notification to the regional supervisor shall be made during the
normal office hours from 8:00 a.m. until 5:00 p.m. on Monday through Friday, excluding State
Holidays.
Pursuant to 15A NCAC 2H .0140, upon completion of construction and prior to operation of
these permitted facilities, the completed Engineering Certification form attached to this permit shall be
submitted to the address provided on the form.
Upon classification of the facility by the Certification Commission, the Permittee shall
employ a certified wastewater treatment plant operator to be in responsible charge (ORC) of the
wastewater -treatment -facilities. The operator must hold_a-certificate of the type -and -grade at.least
equivalent to or greater than the classification assigned to the wastewater treatment facilities by
the Certification Commission.
The Permittee must also employ a certified back-up operator of the appropriate type and
grade to comply with the conditions of T15A:8G.0202. The ORC of the facility must visit each
Class I facility at least weekly and each Class H, III and IV facility at least daily, excluding
weekends and holidays, must properly manage the facility, must document daily operation and
maintenance of the facility, and must comply with all other conditions of T15A:8G.0202.
A copy of the approved plans and specifications shall be maintained on file by the
Permittee for the life of the facility.
During the construction of the proposed additions/modifications, the permittee shall
continue to properly maintain and operate the existing wastewater treatment facilities at all times,
and in such a manner, as necessary to comply with the effluent limits specified in the NPDES
Permit.
You are reminded that it is mandatory for the project to be'constructed in accordance
with the North Carolina, Sedimentation Pollution Control Act, and, when applicable, the North
Carolina Dam Safety Act. In addition, the specifications must clearly state what the contractor's
responsibilities shall be in complying with these Acts.
Failure to abide, by the requirements contained in this Authorization to Construct may
subject the Permittee to an enforcement action by the Division of Water Quality in accordance
with North Carolina General Statute 143-215.6A to 143-215.6C.
The issuance of this Authorization to Construct does not preclude the Permittee from
complying with any and all statutes, rules, regulations, or ordinances which may be imposed by
other government agencies (local, state, and federal) which have jurisdiction.

Ms. Pamela Edwards_ Ford
March 22, 2006
Page 3
i If you have any questions or need additional information, please do not hesitate to contact
Cecil G. Madden, Jr., P.E. at telephone number [phone].
Sincerely,
Alan W. Klimek, P.E.
MH/cgm
cc: Donald Munday, P.E. — Piedmont Design Associates, P.A.
Iredell County Health Department
t1Vlooresville-Regional Office; Surface Water P-6-Ccti7oT
Technical Assistance and Certification Unit
S Daniel Blaisdell, P.E.
Point Source Branch, NPDES Program
Cecil G. Madden, Jr., P.E.
Mark Hubbard, P.E.
A to C File

Hill Haven Residential Care, Inc.
A to C No. 045012A01
Issued March 22, 2006
Engineer's Certification
I, , as a duly registered Professional Engineer in
the State of North Carolina, having been authorized to observe (periodically/weekly/full time)
the construction of the modifications and improvements to the Hill Haven Residential Care, Inc.
WWTP, located on Oak Haven Drive'in Iredell County for Hill Haven Residential Care, Inc.,
hereby state that, to the best of my abilities, due care and diligence was used in the observation
of the following construction:
I Installation of a sodium sulfite tablet dechlorination system, pursuant to the fast
track application received on March 21, 2006, and in conformity with the
Minimum Design Criteria for,Dechlorination Facilities.
I certify that the construction -of the above referenced project was observed to be built
within substantial compliance and intent of the approved plans and specifications.
Signature
Registration N,
Date
Send to: Construction Grants & Loans
DENR/DWQ
1633 Mail Service Center
Raleigh, NC 27699-1633

A74LA
NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
;Michael F. Easley, Governor
LI
Ms. Pamela Edwards Ford
Hill Haven Residential Care, Inc.
142 Oak Haven Drive
Statesville, NC 28625
August 30, 2005
Subject: Waiver of Monthly Reporting Requirement
Hill Haven Residential Care, Inc. WWTP
NPDES Permit NCO045012
Iredell County
Dear Ms. Ford:
William G. Ross, Jr., Secretary
Alan W. Klimek, P.E., Director
w
200.)
Title 15A of the North Carolina Administrative Code, Subchapter 2B, Section .0506 enumerates
specific reporting requirements applicable to holders of NPDES permits issued by the State of
North Carolina. 15A NCAC 2B .0506 (a)(1)(E) states that permittees must continue to submit
monthly discharge monitoring reports (DMRs) to the Division of Water Quality, even when there
is no discharge from the facility during the reporting period. This requirement may be waived by
the Director of the Division of Water Quality during extended periods of no discharge.
I have reviewed your correspondence of August 23, 2005 which described the current status of
the Hill Haven facility. You note that the facility has been closed for three years and no influent
is entering the wastewater treatment plant (WWTP).
After reviewing your letter and considering the recommendation of the staff of the Mooresville
Regional Office, I have agreed to waive the requirement to submit monthlMRs for the subiect
facility, effective with the August 2005 DMR. Additionally, I hereby waive the requirement for
operator visitation at this facility. Please keep the Surface Water Protection Section of the
Mooresville Regional Office apprised of any pertinent developments that arise regarding the
future use of this facility. After such a long period of inactivity, you may face operational
challenges if the facility is reopened and the WWTP is again put in use. The Mooresville
Regional Office staff will be able to assist you and your operator as you look toward restarting
the WWTP. Please be aware that if the WWTP does resume operations, visitation, monitoring
and reporting must also resume as required by the terms of the permit and North Carolina's
environmental laws.
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] / FAX [phone] / Internet:: h2o.enr.state.nc.us
An Equal Opportunity/Affirmative Action Employer — 50% Recycled/10% Post Consumer Paper
Nne
orthCarolina
Naturaliff

Ms. Pamela Edwards Ford
NC0045012 Reporting Waiver
p. 2
Please also be advised that while requirements for operator visitation, monitoring and reporting
are being waived— during the period of no discharge;I3ill-Haven Residential Care, lnc. is still------
required to pay the Annual Administering and Compliance Monitoring Fee that is associated
with this and all NPDES permits.
Thank you for your cooperation in this matter. If you have any questions, please contact the
Surface Water Protection Section staff in our Mooresville Regional Office at [phone], or
Bob Sledge in our Raleigh central office at [phone], extension 547.
Sincerely,
Alan W. Klimek, P.E.
c6 Mooresville Regional Office= ;SWP-Section
Point Source Branch - Charles Weaver
Jeanne Phillips
Central Files .

NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES'
M,OORESVILLE REGIONAL OFFICE
February 1, 2000
Ms. Pamela Edwards
Hill Haven Residential Care, Inc.
Statesville, North Carolina 28677
Permit No. NC0045012'
Hill Haven Residential Care, Inc.
Iredell County, NC
Dear Ms. Edwards:
Our records indicate that NPDES Permit No. NCO045012 was issued on January
25, 2000 for the discharge of wastewater to the surface waters of the State from your
facility. The purpose of this letter is to advise you of the importance of the Permit and
.the liabilities in the event of failure to comply with the terms and conditions of the
Permit. If you have not already done so, it is suggested that you thoroughly read the
Permit. Of particular importance are Pages 4 and 5.
Pages 4 and 5 set forth the effluent limitations and monitoring
requirements for your discharge. Your discharge must not exceed any of the limitations
set forth. The section headed "Monitoring Requirements" describes the measurement
frequencies, sample types and sampling locations. Upon commencement of your
discharge (or operation), you must initiate the required monitoring. The monitoring
results must be entered on reporting forms furnished or approved by this Agency. If you
have not received these forms, they should be arriving shortly. If you fail to receive the
forms, please contact this Office as quickly as possible. I have enclosed a sample of the
"Effluent" reporting form (DEM Form MR-1), plus instructions for completing the form.
It is imperative that all applicable parts be completed, and the original and one copy be
submitted as required.
Please be advised that -an annual administering and compliance monitoring fee
may be required for your facility. You will soon be receiving -a statement from our
Raleigh Office. It is imperative that the -fee be paid in a timely manner so as to prevent
enforcement action or possible revocation of your permit.
2 0 1 0
919 NORTH MAIN STREET, MOORESVILLE, NORTH CAROLINA 28115
PHONE [phone] FAX [phone]
AN EQUAL OPPORTUNITY / AFFIRMATIVE ACTION EMPLOYER - 50% RECYCLED/10% POST -CONSUMER PAPER

Ms. Edwards
February 1, 2000
The remaining parts of the Permit set forth definitions, general conditions and
special conditions applicable to the operation of wastewater treatment facilities and/or
discharge(s). The conditions include special reporting requirements in the event of
noncompliance, bypasses, treatment unit/process failures, etc. Also addressed are
requirements for a certified wastewater treatment plant operator if you are operating
wastewater treatment facilities. Any changes in operation of wastewater treatment
facilities, quantity and type of wastewater being treated or discharged, expansion and/or
upgrading of wastewater treatment facilities must be permitted or approved by this
Agency.
Failure to comply with the terms and conditions of an NPDES Permit subjects
the Permittee to enforcement action pursuant to Section 143-215.6 of the North Carolina
General Statutes. A civil penalty of up to $25,000 per violation (and/or criminal
penalties) may be assessed for such violations. If you find at any time that you are
unable to comply with the terms and conditions of the Permit, you should contact this
Office immediately. A Special Order by Consent (SOC) may be necessary while
pursuing action to obtain compliance.
As a final note, an NPDES Permit is normally issued for a five-year period.
Permits are not automatically renewed. Renewal requests must be submitted to this
Agency no later than 180 days prior to expiration. Please make note of the expiration
date of your Permit. This date is set forth on Page 1 of the Permit. Also note that
NPDES Permits are not automatically transferable. If you, as the Permittee, cease to
need this Permit, then you should request that the Division of Water Quality rescind the
Permit or request that the Division of Water Quality reissue the Permit to another party,
if necessary.
As mentioned previously, the purpose of this letter is to advise you of the
importance,of your NPDES Permit. Please read the Permit and contact this Office at
704/663-1699 in Mooresville of you have any questions or need clarification. We look
forward to providing any assistance.
Sincerely,
D. Rex Gleason, P.E.
Water Quality Regional Supervisor
Enclosure
DRG: de

State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Bill Holman, Secretary
Kerr T. Stevens, Director
Ms. Pamela Edwards
Hill Haven Residential Care. Inc.
114 Hill Haven Road
Statesville, North Carolina 28677
Dear Ms. Edwards:
AW
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
g.�pyq�gpfti^.C_ -DYJP ,T .: tp ram,,
NAT
January 25. 2000
B
190Afi1U RI�T)A9. 0
Subject: Issuance of NPDES Permit M 0045012
Hill Haven Residential Care, Inc.
Iredell County
This letter is to inform you that the Division has finalized its review and the comment period is now
closed for NPDES permit NC0045012. A final copy of the permit is attached to this letter. This permit is issued
pursuant to the requirements of the North Carolina General Statute 143-215.1 and the Memorandum of
Agreement between North Carolina and the US Environmental Protection Agency dated December 6, 1983.
The following list has been included to outline the changes that were addressed in the draft permit.
These changes remain in the final permit.
Quarterly monitoring for Total Nitrogen and Total Phosphorus has been included. The- Division has
included these monitoring requirements for all permitted discharges in the Yadkin Basin. The results
of this additional monitoring will be used in the development of a nutrient management strategy for
the Yadkin Basin.
Effluent temperature monitoring has changed from weekly to daily. Daily temperature monitoring is
required for all Class I facilities. This requirement is outlined in NC Administrative Code 213.0500.
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. In addition, this permit does not affect the legal
requirement to obtain other permits which may be required by the Division of Water Quality or permits required
by the Division of Land Resources, Coastal Area Management Act or any other Federal or Local governmental
permit that may be required. If we can be of further assistance to you, please do not hesitate to contact Charles
Weaver of my staff at [phone], extension 511.
Sincerely,
Original Signed 6y
®avid A. Goodrich
Kerr T. Stevens
cc: Central Files
p1 Ioares� i =1'e�RegionRI O 17er_,`:
Point Source Compliance Enforcement Unit
NPDES Unit / Permit file
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post -consumer paper

Permit NCO045012
4 STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
4 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,
Hill Haven Residential Care, Inc.
is hereby authorized to discharge wastewater from a facility located at
Hill Haven Residential Care
i 114 Hill Haven Road
t Statesville
Iredell County
to receiving waters designated as an unnamed tributary to Third Creek in the Yadkin -Pee Dee River Basin
in accordance with effluent limitations, monitoring requirements, and other conditions set forth in Parts I,
11, III, and IV hereof.
The permit shall become effective March 1, 2000
This permit and the authorization to discharge shall expire at midnight on -July 31, 2004
Signed this day January 25, 2000
Original Signed By
®avid A Goodrich
Kerr T. Stevens, Director
Division of Water Quality
By Authority of the Environmental Management Commission

Permit NC04.50112
SUPPLEMENT TO PERMIT COVER SHEET
Hill Haven Residential Care, Inc., is hereby authorized to:
1. Continue to operate an existing 0.018 MGD wastewater treatment plant with
the following components:
Two septic tanks
➢ Two surface sand filters
Effluent chlorination
This facility is located at Hill Haven Residential Care at 114 Hill Haven Road
near Statesville in Iredell County.
2. Discharge from said treatment works at the location specified on the
attached map into'an unnamed tributary to Third Creek, classified C waters
in the Yadkin -Pee Dee River Basin. .

Latitude:
35044' 50"
Longitude:
800 53' 41"
USGS Quad #:
E15NW
River Basin #:
03-07-06
Receivina Stream: UT to Third Creek
Stream Class:
C
YILI- 11'4VC-1V
Residential Care, Inc.
NCO045012
Iredell County

A.(1) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS
Permit No. NCO045012
During the period beginning on the effective date of the permit and lasting until expiration, the Permittee is authorized to discharge from outfall
serial number 001. Such discharges shall be limited and monitored by the Permittee as specified below:
EFFLUENT CHARACTERISTICS
LIMITS
MONITORING REQUIREMENTS
Monthly
Average
Weekly
Average
Daily
Maximum
Measurement
Frequency
Sample
Type
Sample
Location'
Flow
0.018 MGD
Weekly
Instantaneous
I or E
BOD, 5 day, 20°C
30.0 m /I
45.0 m /I
2/Month
Grab
E
Total Suspended Solids
30.0 m /I
45.0 m /I
2/Month
Grab
E
NH as N (April 1 to October 31)
9.4 m /I
2/Month
Grab
E
NH as N November 1 to March 31
30.0 m /I
2/Month
Grab
E
Fecal Coliform(geometric mean
200 / 100 ml
400 / 100 ml
2/Month
Grab
E
Total Residual Chlorine
2/Week
Grab
E
Temperature
Daily
Grab
E
Total Nitrogen NO + NO + TKN
Quarterly
Grab
E
Total Phosphorus
Quarterly
Grab
E
PH'
2/Month
I Grab A
E
Notes•
' Sample locations: I —Influent, E —Effluent.
The pH shall not be less than 6.0 standard units nor greater than 9.0 standard units.
There shall be no discharge of floating solids or visible foam in other than trace amounts.

PART I
Section B. Schedule of Compliance
1. The permittee shall comply with Final Effluent Limitations specified for discharges in accordance
with the following schedule:
Permittee shall comply with Final Effluent Limitations by the effective date of the permit unless
specified below.
2. Permittee shall at all times provide the operation and maintenance necessary to operate the
existing facilities at optimum efficiency.
3. No later than 14 calendar days following a -date identified in the above schedule of compliance,
the permittee shall submit either a report of progress or, in the case of specific actions being
required by identified dates, a written notice of, compliance or noncompliance. In the latter case,
the notice shall include the cause of noncompliance, any remedial actions taken, and the
probability of meeting the next schedule requirements.

Part II
Page 1 of 14
PART II
STANDARD CONDITIONS FOR NPDES PERMITS
SECTION A. DEFINITIONS
1. Permit Issuing Authority
The Director of the Division of Water Quality.
2. DEM or "the Division"
Means the Division of Water Quality, Department of Environment, Health and Natural Resources.
3. EMC
Used herein means the North Carolina Environmental Management Commission.
4. Act or "the Act"
The Federal Water Pollution Control Act, also known as the Clean Water Act, as amended, 33 USC
1251, et. seq.
5. Mass/Day Measurements
a. The "monthly average discharge" is defined as the total mass of all daily discharges sampled
and/or measured during a calendar month on which daily discharges are sampled and
measured, divided by the number of daily discharges sampled and/or measured during such
month. It is therefore, an arithmetic mean found by adding the weights of the pollutant found
each day of the month and then dividing this sum by the number of days the tests were
reported. The limitation is identified as "Monthly Average" in Part I of the permit.
b. The "weekly average discharge is defined as the total mass of all daily discharges sampled
and/or measured during the calendar week (Sunday - Saturday) on which daily discharges are
sampled and measured, divided by the number of daily discharges sampled and/or measured
during such week. It is, therefore, an arithmetic mean found by adding the weights of
pollutants found each day of the week and thendividing this sum by the number of days the
tests were reported. This limitation is identified as "Weekly Average" in Part I of the permit.
c. The "maximum daily discharge is the total mass (weight) of a pollutant discharged during a
calendar day. If only one sample is taken during any calendar day the weight of pollutant
calculated from it is the "maximum daily discharge." This limitation is identified as "Daily
Maximum," in Part I of the permit.
d. The "average annual discharge" is defined as the total mass of all daily discharges sampled
and./or measured during the calendar year on which daily discharges are sampled and
measured, divided by the number of daily discharges sampled and/or measured during. such
year. It is, therefore, an arithmetic mean found by adding the weights of pollutants found each
day of the year and then dividing this sum by the number of days the tests were reported. This
limitation is defined as "Annual Average" in Part I of the permit.

Part II
Page 2 of 14
6. Concentration Measurement
a. The "average monthly concentration," other than for fecal coliform bacteria, is the sum of the
concentrations of all daily discharges sampled and/or measured during a calendar month on
which daily discharges are sampled and measured, divided by the number of daily discharges
sampled and/or measured during such month (arithmetic mean of the daily concentration
values). The daily concentration value is equal to the concentration of a composite sample or in
the case of grab samples is the arithmetic mean (weighted by flow value) of all the samples
collected during that calendar day. The average monthly count for fecal coliform bacteria is
the geometric mean of the counts for samples collected during -a calendar month. This
limitation is identified as "Monthly Average" under "Other Limits" in Part I of the permit.
b. The "average weekly concentration," other than for fecal coliform bacteria, is the sum of the
concentrations of all daily discharges sampled and/or measured during a calendar week
(Sunday/Saturday) on which daily discharges are sampled and measured divided by the
number of daily discharges sampled and/or measured during such week (arithmetic mean of the
daily concentration values). The daily concentration value is equal to the concentration of a
composite sample or in the case of grab samples is the arithmetic mean (weighted by flow
value) of all the samples collected during that calendar day. The average weekly count for
fecal coliform bacteria is the geometric mean of the 'counts for samples collected during a
calendar week. This limitation is identified as "Weekly Average" under "Other Limits" in
Part I of the permit.
c. The "maximum daily concentration" is the concentration of a pollutant discharge during a
calendar day. If only one sample is taken during any calendar day the concentration of
pollutant calculated from it is the "Maximum .Daily Concentration". It is identified as "Daily
Maximum" under "Other Limits" in Part I of the permit.
d. The "average annual concentration," other than for fecal coliform bacteria, is the sum of the
concentrations of all daily. discharges sampled and/or measured during a calendar year on
which daily discharges are sampled and measured divided by the number of daily discharges
sampled and/or measured during such year (arithmetic mean of the daily concentration
values). The daily concentration value is equal'to the concentration of a composite sample or in
the case of grab samples is the arithmetic mean (weighted by flow value) of all the samples
collected during that calendar day . The average yearly count for fecal coliform bacteria is the
geometric mean of the counts for samples collected during a calendar year. This limitation is
identified as "Annual Average" under "Other Limits" in Part I of the permit.
e. The "daily average concentration" (for dissolved oxygen) is the minimum allowable amount of
dissolved oxygen required to be available in the effluent prior to discharge' averaged over a
calendar day. If only one dissolved oxygen sample is taken. over a calendar day, the sample is
considered to be the- "daily average concentration" for the discharge. It is identified as "daily
average" in the text of Part 1. -
f. The "quarterly average concentration" is the average of all samples taken over a calendar
quarter. It is identified as "Quarterly. Average Limitation" in the text of Part I of the permit.
g. A calendar quarter is defined as one of the following distinct periods: January through March,
April through June, July through September, and October through December.

Part II
Page 3 of 14
7. Other Measurements aged
is the 24 hours
e flow, aver
a. Flow,.(M
GD): The flow limit expressed in this permthe total daily flows recgorded during the
ed .as the arithmetic mean
f t
monthly. It is determino
calendar month.
of flow
ken at the
b. An
"instantaneous flow measurement" is a measure the total discharge
both the sample and flow will betime of sampling, when
, representative
ow
facility which
urs
fl
C.
A "continuous flow measurement is a measure he oa schareratigeho s. there may be no flow or from
hehfacility. Flow shall be
for
continually without interruption .throughou
monitored continually except for the flowfregdevice uent times when
infrequent maintenance activities on the .
8. Lroes of Samvles
a. Composite Sample: A composite sample shall consist of: riod of discharge
(1) a series of grab samples cnaleto he rate ofllcted at equaltflowimelmeasurntervalsed at the time of individual sample
and combined proportio
collection, or r A 24 hour period with the time 2) a series of grab samples of equal volumeacollected
n tuber of gallons passing the sapling
ng
intervals between samples determined by preset
ow
point. Flow measurement.betweTn sampleinte
interval between samples olle lion fixed at
recorder and totalizer, and the p gallon
no greater than 1 /24 of the expected eed over a 241hou� peri d proporw at the tional to the rate of flow.
(3) a single, continuous sample co
nfluent
ab
In accordance with (1) above, the time intery Vabebet {We n effluent grab samples
shall be no
greater than once per hourtion time Of
, and the time inter
greater than once per hour except at wastewaer treatment
e samples Ymay be collected at time intervals
greater than 24 hours. In such cases, effluentgrab
evenlyon time
spaced over the 24 hour period which area case may the of hours to thbedet '
of the system in number tl
Peffluentt
of days. However,
grab samples be greater than six (6) hours nor the number of samples less than four (4) during
24 hour sampling period.
be taken manually. Grab samples must - be
t.
b.
Grab Sample: Grab samples are individual samples collected over a period of. time no
exceeding 15 minutes; the grab sample c
representative of the discharge or the receiving waters.
9: Calculation of Means
metic Mean: The arithmetic mean of any set of values is the summation of the individual
a Anth is
values divided by the number of individual values.
Nth'root'of the
b. Geometric Me
an: ry The geometric mean of any set of values duae values. The geometric cmean is
individual values where N is equal to the number of ind
equi
valent to the antilog of the arithmetic mean hoflzero logarithms
ms of the individual values
be tconsidered to al one
For purposes of calculating the geometric mean, values
(1).
b Flow Value: Weighted by flommarion w value means -the he respectnive flows.mation f each concentration
c. WeightedY
times its respective flow divided by the su

Part II
Page 4 of 14
10. Calendar Day
A calendar, day is defined as the period from midnight of one day until midnight of the, next day.
However, for purposes of this permit, any consecutive 24-hour period that reasonably represents
the calendar day may be used for sampling.
11. Hazardous Substance
A hazardous substance means any substance designated under 40 CFR Part 116 pursuant to Section
311 of the Clean Water 'Act.
12. Toxic Pollutant
A toxic pollutant is any pollutant listed as toxic. under Section 307(a)(1) of the Clean Water Act.
SECTION B. GENERAL CONDITIONS
1. Duty to Comply
The permittee must comply with all conditions of this permit. Any permit noncompliance
constitutes a violation of the Clean Water Act and is grounds for enforcement action; for permit
termination, revocation and reissuance, or modification; or denial of a permit renewal application.
a.. The permittee shall comply with effluent standards or prohibitions established under section
307(a) of the Clean Water Act for toxic pollutants and with standards for sewage sludge use or
disposal established under section 405(d) of the. Clean Water Act within the time provided in
the regulations that establish these standards or prohibitions. or standards for sewage sludge
use or disposal, even if the.permit has not yet been modified to incorporate the requirement.
b. The Clean Water Act provides that any person who violates a permit condition is subject to a
civil penalty not to exceed $25;000 per day for each violation. Any person who negligently
violates any permit condition is subject to criminal penalties of $2,500 to $25,000 per day of
violation, or imprisonment for not more than 1 year, or both. Any person who knowingly
violates permit conditions is subject to criminal penalties of $5,000 to.$50,000 per day of
violation, or imprisonment for not more than 3 years, or both. Also,.any person who violates a
permit condition may be assessed an administrative penalty not to exceed $10,000 per violation
with the maximum amount not to exceed $125,000. [Ref: Section 309 of the Federal Acf 33
U.S.C. 1319 and 40 CFR 122.41 (a)] -
c. Under state law, a civil penalty of not more than, ten thousand dollars ($10,000) per violation
may be assessed against any person who violates or fails to act in accordance with the terms,
conditions, or requirements of a permit. [Ref: North Carolina General Statutes § 143-215.6A]
d. Any person may be assessed an administrative penalty by the Administrator for violating
section 301, 302, 306, 307, 308, 318, or 405 of the Act,- or any permit condition or limitation
implementing any of ,such sections in a permit issued under section 402 of the Act.
Administrative penalties for Class I violations are not to exceed $10,000 per violation, with
the maximum amount of any Class I penalty assessed not to exceed $25,000. Penalties for Class
II violations are not to exceed $10,000 per day for each day during which the violation
continues, with the maximum amount of any Class 11 penalty not to exceed $125,000.

Part II
Page 5 of 14
2. Dui to Mitigate ,
The permittee shall take all reasonable steps to minimize or.prevent any discharge or sludge use or
disposal in violation of this permit which has a reasonable' likelihood of adversely affecting
human health or the environment.
3. Civil and Criminal Liability
Except as provided in permit conditions on 'Bypassing" (Part I1, C-4) and "Power Failures" (Part 11,
C-7), nothing in this permit shall be construed to relieve the permittee from any responsibilities,
liabilities, or penalties for noncompliance pursuant to NCGS 143-21.5.3, 143-215.6 or Section 309 of
the Federal Act, 33 USC 1319. Furthermore, the permittee is responsible for consequential damages,
such as fish kills, even though the responsibility for effective compliance may be temporarily
suspended.
4. Oil and Hazardous Substance Liability
Nothing in this permit shall be construed to preclude the institution of any legal action or relieve
the permittee from any responsibilities, liabilities, or penalties to which the permittee is or may
be 'subject to under NCGS 143-215.75 et. seq. or Section 311 of the Federal Act, 33 USG 1321.
Furthermore, the permittee is responsible for consequential damages, such as fish kills, even
though -the responsibility for effective compliance may be temporarily suspended.
5. Property Rights
The issuance of this permit does not convey any property rights in either real or personal property,
or any exclusive privileges, nor does it authorize any injury to private property or any invasion of
personal rights, nor any infringement of Federal, State or local laws or regulations.
6. Onshore or Offshore Construction
This -permit does not authorize or approve the construction of any onshore or offshore physical
structures or facilities or the undertaking of any work in any navigable waters.
7. Severability
The provisions of this permit are severable; and if any provision of this permit, or the application
of any provision of this permit to any circumstances, is held invalid, the application of such
provision to. other circumstances, and the remainder of this permit, shall not be affected thereby.
8. Du1y to Provide Information
The permittee shall furnish to the Permit Issuing- Authority, within a .reasonable time, any
information which the Permit Issuing Authority may request to determine whether cause exists for
modifying, revoking and reissuing, or terminating this permit .or to determine compliance with this
permit. The permittee shall also furnish to the Permit Issuing Authority upon request, copies of
records required to be kept'by this permit.
9. Duty to Reapply
If the permittee wishes to continue an activity regulated by this permit after the expiration date of
this permit, the permittee must apply for and obtain a new permit.

Pan 11
Page 6 of 14
10. Expiration of Permit
The permittee is not authorized to discharge after the. expiration date. In order to receive
automatic authorization to discharge beyond the expiration date, the permittee shall submit such
information, forms, and fees as are required by the agency authorized to issue permits no later -than
180 days prior to the expiration date. Any permittee that has not requested renewal at least 180
days prior to expiration, or any.permittee that does not have a permit after the expiration and has
not requested renewal at least 180 days prior to expiration, will subject the permittee to enforcement
procedures as provided in NCGS 143-215.6 and 33 USC 1251 et. seq.
11. Signatory Requirements
All applications, reports, or information submitted to the Permit Issuing Authority shall be signed
and certified.
a. All permit applications shall be signed as follows:
(1) For a corporation: by a responsible corporate officer. For the purpose of this Section, a
responsible corporate officer means: (a) a president, secretary, treasurer or vice president
of the corporation in charge of a principal business function, or any other person who
performs similar policy or decision making functions for the corporation, or (b) the manager
of one or more manufacturing production or operating facilities employing more than 250
persons or having gross annual sales or expenditures exceeding 25 million (in second quarter
1980 dollars), if authority to sign documents has been assigned or delegated. to the manager
in accordance with corporate procedures.
(2) . For a partnership or sole proprietorship: by a general partner or the proprietor,
respectively; or
(3) For a municipality, State, Federal, or other public agency: by 'either a principal executive
officer or ranking elected official.
b. All reports required by the permit and other information requested by the Permit Issuing
Authority shall be signed by a person. described above or by a duly authorized representative of
that person. A person is a duly authorized representative only if:
(1) The authorization is made in writing by a person described above;
(2) The authorization specified either an individual or a ,position having responsibility for the
overall- operation of the. regulated facility or activity, such as the position of plant
manager, operator of a well or well field, superintendent, a position of equivalent
responsibility, or an individual or position having overall responsibility for environmental
matters for the company.. (A duly authorized representative may thus be either a named_
individual or any individual occupying a named position.); and
(3) The written authorization is submitted to the Permit Issuing Authority.
c. Certification. .Any person signing a document under paragraphs a. or b. -of this section shall
make the following certification:
"I certify, under penalty of law; that this document and all attachments were prepared under
MY direction or supervision in accordance with a system designed to assure that qualified
personnel properly'gather and evaluate the information submitted. Based on my inquiry of the
-person or persons who manage the system, or -those persons directly responsible for gathering
the information, the information submitted is, to the best of my knowledge and belief, true,
accurate, and complete.. I am aware that there are significant penalties. -for submitting false
information, including the possibility of fines and imprisonment for knowing violations."

Part II
Page 7 of 14
12: Permit Actions
for cause.
uest
This permit may be modified; revoked and teori reissued,
revocation lands a ssuance, oretermination,'lof A gor a
by the permittee for a permit modific ,
notification of planned changes or anticipated noncompliance does not stay any permit condition.
13. Permit Modification Revocation and Reissuance or Termination
issuance of this permit does not prohibit the permit issuing, authority from as allowed y
ening and
The issua P .
modifying the permit, revoking and reissuing the permit, or terminating Pe
the laws, rules, and regulations contained n Title 40ive CodeCode , Subchapter Federal
.0100 wand North
123; Title 15A of the North Carolina Ad
Carolina General Statute 143-215.1 et. al.
14. Previous Permits
its
All previous National Pollutant DischargebElrev�oked by issuance of nation th s permit. . t I'�c' excluo this sive
whether for operation or discharge, are ye the facility
it. The authority to operat
authority to operate this facility arises under numberhis nis no longer effective. I The conditions,
under previously issued permits bearing this
requirements, terms, and provisions - of this. per
Pollutant Discharge Elimination System govern discharges from tmit authorizing his
facility discharge under the" National
1. Certified Operator
General
on classification of the
Pursuant to Chapter 90A-44 of North Carothe ermitt a Statutes,
pemploya certified wastewater
facility by the Certification Commission, p
treatment plant operator in responsible charg(OeCuivalent tof the sor greater than the classification
operator must hold a certification of the gradqssion. The
assigned to the wastewater treattee
ment facilities afar of the approthe 1priatie .type and any grade, toecomtply
must also employ a certified back-up opmust visit
with the -conditions of Title 15A, Chapter I8 III0and IV f 02. The Ocil tyoattleastcdailaClass
y, excluding weekends
facility at least weekly and each Class ,
and holidays, and must properly manage
an conditions of Title 1cument daily 5ArChapter 8A .0202.anOnce the
facility and must comply with all of to the her
facility is classified, permittee shall submit th nttthi thirty days afterthewasttewater�treatment
designates the operator in responsible charge
facilities are 50% complete.
2. Proper Operation and Maintenance
The permittee shall at all times properly operate and ma
intain all.facilities and systems of
T pinstalled or used by the permittee to
treatment and control (and related appurtenances) which are
achieve compliance with the conditions of this permit.quality assurrance procedureser operation and .Thisprovision
includes adequate laboratory controls and app p
or auxil
requires the.operation of back-up iary yto achieve compliance with the conditionmilar systems.which arels ed of he
permittee only when the operation is necessary
permit.

Part II
Page 8 of 14
g, N to Halt r Reduce not a Defense
r to main
compliance with the condition of this
hall not be a defense for a permittee in an enm
forcement action that it would have been necessary
It s
to halt or reduce the. permitted activity in order
! permit.
4. B assin of Treatment Facilities
a. Definitions from any portion of a
B ass" means the known diversion of a
ste streams
(1) is not designed or establ shed or treatment
g
yP
facility including the collection system, which damage to the
mode for the facility.
(2) "Severe property damage" means substantial physical damage to property,
treatment facilities which causes them to become bnop erectedoto occur in the absence of a
loss of natural resources which can reasonably P
bypass. Severe property damage does not mean economic loss caused by delays in
YP
production.
b. Bypass not exceeding limitations.
The permittee may allow any bypass. to occur which does not cause effluent limitations to be
Pto
Th
exceeded, but only if it also is for essential
l rae hs ceanci dsof thisf se
ure operation. on.ese
bypasses are not subject to the provisions of Para $ P
c. Notice e of the need
Antici ated bypass. If the permittee knows in advancthe d te.of thefbypass; including aor a bypass, it l
(1) Pbefore
n
submit prior notice, if -possible at least ten days
evaluation of the anticipated quality and affect of the bypass.
(2) Unanticipated bypass. The permittee 2 all submit
noticenotice of an unanticipated bypass as
. required in Part II, E. 6. of this permit
d. Prohibition of Bypass
1 .B hibited and the Permit Issuing Authority may take enforcement action against.
() .Bypass is pro
a permittee for bypass, unless:
(A) Bypass wa
s unavoidable to prevent loss of lifepersonal injury or severe property
,
damage;such as
eatment
(B) There were no feasible alternatives t the
bopar. maintenance during f normal auxiliary rof
facilities, retention of untreated wastes
ent to revent a bypass
equipment downtime. This Conde of reasonable sengineering judgmfied if adequate kup egpreve should
have been installed in the exert
ds of equipment downtime or preventive maintenance
which occurred during normal perio;
and
ired under Paragraph c: of.this section.
(C) The permittee submitted notices as requ
issuing Authority may approve an an ete -ties that sit swill meet considering
three
fter
(2) The Permit g
adverse affects, if .the Permit issuing Authority determin
conditions listed above in Paragraph d. (1) of this. section..

Part II .
Page 90 14
5. Upsets
a. Definition.
"Upset " means an exceptional incident in which there is unintentional and temporary
noncompliance with technology based permit effluent limitations because of factors beyond the
reasonable control of the permittee. An upset does not include noncompliance to the extent
caused by operational error, improperly designed treatment facilities, inadequate treatment
facilities, lack of preventive maintenance, or careless or improper operation.
b. Effect of an.upset.
An upset constitutes an affirmative defense to an action brought for noncompliance with such
technology, based permit effluent limitations if the requirements of paragrapht c. of this
condition are met. No determination made during administrative review of claims that
noncompliance was caused by upset,',
pset, and before an action for noncompliance, is final
administrative action subject to judicial review.
c. Conditions necessary for a demonstration of upset.
A permittee who wishes to establish the affirmative defense of upset shall demonstrate,
through properly signed, contemporaneous operating logs, or other relevant evidence,that:
(1) An upset occurred and that the pernuttee can identify the causes) of the upset;
(2) The permittee facility was at the time being properly operated; and
(3) The permittee submitted notice of the upset as required in Part II, E. 6. (b) (B) of this permit.
(4) The permittee complied with any remedial measures required under Part Il, B. 2. of this
permit.
d. Burden of proof.
In any enforcement proceeding the permittee seeking to establish the occurrence of an upset has
the burden of proof.
6. Removed Substances
Solids, sludges, filter backwash, or other pollutants removed in the course of treatment or control of
wastewaters shall be utilized/disposed of in accordance with NCGS 143-215.1 and in a manner such
as to prevent any pollutant from such materials from entering waters of the State or navigable
waters of the United States. , The permittee shall comply with all existing federal regulations
governing the disposal of sewage sludge. Upon promulgation of 40 CFR Part 503, any permit issued
by the Permit Issuing Authority for the utilization/disposal of sludge may be reopened and
modified, or revoked and reissued, to incorporate applicable requirements at 40 CFR Part 503. The
permittee shall comply with applicable 40 CFR Part 503 Standards for the Use and Disposal of
Sewage Sludge (when promulgated) within the time provided in the regulation, even if the permit
is not modified to incorporate the requirement. The permittee shall notify the Permit Issuing
Authority of any significant change in its sludge use or disposal practices.
7. Power Failures
The permittee is responsible for maintaining adequate safeguards as. required 'by DEM Regulation,
Title 15A, North Carolina Administrative Code, Subchapter 2H, .0124 Reliability, to prevent the
discharge of untreated or inadequately treated wastes during electrical power failures either by
means of alternate power sources, standby generators or retention of inadequately treated effluent.

Part II
Page 10 of 14
SECTION D. MONITORING AND RECORDS
1. Representative Sampling
Samples collected and measurements taken, as required herein,, shall be characteristic of the
volume and nature of the permitted discharge. Samples collected at a frequency less than daily
shall be taken on a day and time. that is characteristic of the discharge over the entire period
which the sample represents. All samples shall be taken at the monitoring points specified in this
permit and, unless. otherwise specified, before the effluent joins' or is diluted. by -.any other
wastestream, body of water, or substance. Monitoring points shall not be .changed without -
notification to and the approval of the.Permit Issuing Authority.
2. Reporting
Monitoring results obtained during the previous month(s) shall be summarized for each month and
reported on a monthly Discharge Monitoring Report (DMR) Form (DEM No. MR 1, 1.1, 2,. 3) or
alternative forms approved by the Director, DEM, postmarked no later than the 30th" day
following the completed reporting period.
The first DMR is due on the last day of the month following the issuance of the permit or in the case
of a new facility, on the last day of the .month following, the commencement of discharge.
Duplicate signed copies of these, and all other reports required -herein, shall be submitted to the
following address:
Division ' of Water Quality
Water Quality Section
ATTENTION: Central Files
.Post Office Box 29535
Raleigh, North Carolina 27626-0535
3. Flow Measurements
Appropriate flow measurement devices and methods consistent with accepted scientific practices
shall be selected and used to ensure the accuracy and reliability of measurements of the volume of
monitored discharges. The devices shall be installed, calibrated and maintained to ensure that the
accuracy of the measurements' are consistent with the accepted capability of that type of device.
Devices selected shall be capable of measuring flows with a maximum deviation of less than + 10%
from the true discharge rates throughout the range of expected discharge volumes. Once -through
condenser cooling water flow which is monitored by pump logs,.or pump hour meters as specified in
Part I of this permit and based on the manufacturer's pump curves shall not be subject to this
requirement.
4. Test Procedures
Test procedures for the analysis of pollutants shall conform to the EMC regulations published
pursuant to NCGS 143-215.63 et. seq, the Water and Air Quality Reporting Acts, and to regulations
published pursuant to Section 304(g), 33 USC 1314, of the Federal Water Pollution Control Act, as
Amended, and Regulation 40 CFR 136; or in the, case of sludge use or disposal, approved under 40
CFR 136, unless otherwise specified in 40 CFR 503, unless other test procedures have been specified
in this permit.
To meet the intent of the monitoring required by this permit, all test procedures must produce
minimum detection and reporting levels that are below the permit discharge requirements and all
data generated must be reported down to the minimum detection or lower reporting level of the
procedure. If no approved methods are determined capable of achieving minimum detection and

Part 11
Page 11 of 14
reporting levels below permit discharge requirements, then the most sensitive (method with the
lowest possible detection and reporting level) approved method must be used.
5. Penalties for Tampering
The Clean Water Act provides that any person who falsifies, tampers with, or knowingly renders
inaccurate, any monitoring device or method required to be maintained under this permit shall,
upon conviction, be punished by a fine of not more than $10,000 per violation, or by imprisonment for
not more than two years per violation, or by both. If a conviction of a ,person is for a violation
committed after a first conviction of such person under this paragraph, punishment is a fine of not
more than $20,000 per day of violation, or by imprisonment of not more than 4 years, or both.
6. Records Retention
Except for records of monitoring information required by this permit related to the permittee's
sewage sludge use and disposal activities, which shall be retained for a period of at least five
years (or longer as required by 40 CFR 503), the permittee shall retain records of all monitoring
information, including all.calibration and maintenance records and all original strip chart
recordings for continuous monitoring instrumentation, copies of all reports required by this permit,
for a period of at least 3 years from the date of the sample, measurement, report or application.
This period may be extended by request of the Director -at any time.
7. Recording Results
For each measurement or sample taken pursuant to .the requirements of this permit, the permittee
shall record the following information:
a. The date, exact place, and time of sampling or measurements;
b. The individual(s) who performed the sampling or measurements;
c. The date(s) analyses were performed;
d. The individual(s) who performed the analyses;
e. The analytical techniques or methods used; and
f . The results of such analyses.
8. Inspection and Entry
The permittee shall allow the Director, or an authorized representative (including an authorized
contractor acting as a representative of the Director), upon the presentation of credentials and other
documents as may be required by law, to;
a. Enter upon the permittee's premises where a regulated facility or activity is located or
conducted, or where records must be kept under the conditions of this permit;
b. Have access to and copy, at reasonable times, any records that must be kept under the conditions
of this permit;
C. Inspect at reasonable times . any facilities, equipment (including monitoring and control
equipment), practices, or operations regulated or required under this permit; and
d. Sample or monitor at reasonable times, for the purposes of assuring permit compliance or as
otherwise authorized by the Clean Water Act, any substances or parameters at any location.

Part II
Page 12 of 14
SECTION E. REPORTING REQUIREMENTS
1. Change in Discharge
All discharges authorized herein shall be consistent with the terms and conditions of this permit.
The discharge of any pollutant identified in this permit more frequently than or at a level in excess
of that authorized shall constitute a violation of the permit.
2. Planned Changes
The permittee shall give notice to the Director as soon as possible of any planned physical
alterations or additions to the permitted facility. Notice is.required only when:
a. The alteration or addition to a permitted facility may meet one of the criteria for determining
whether a facility is a new source in 40 CFR Part 122.29 (b); or
b. The alteration or addition could significantly change the nature or increase the quantity of
pollutants discharged. This notification applies to pollutants which are subject neither to
effluent limitations in the permit, nor to notification requirements under 40 CFR Part 122.42 (a)
c. The alteration or addition results in a significant change in the permittee's sludge use or
disposal practices, and such alternation, addition or change may justify the application of
permit conditions that are different from or absent in the existing permit, including notification
of additional use or disposal sites not reported during the permit application process or not
reported pursuant to an approved land application plan.
3. Anticipated Noncompliance
The permittee shall give advance notice to the Director of any planned changes in the permitted
facility or activity which may result in noncompliance with permit requirements.
4. Transfers
This permit is not transferable to any person except after notice to the Director. The Director may
require modification or revocation and reissuance of the permittee and incorporate such other
.requirements as may be necessary under the Clean Water Act.
5. Monitoring Reports
Monitoring results shall be reported at the intervals specified elsewhere in this permit.
a. Monitoring results must be reported on a Discharge Monitoring Report (DMR) (See Part 11. D. 2
of this permit) or forms provided by the Director for reporting results of monitoring of sludge use
or disposal practices.
b. If the permittee monitors any pollutant more frequently than required by the permit, using test
procedures specified in Part II, D. 4. of this permit or in the case of sludge use or disposal,
approved under 40 CFR 503, or as specified. in this permit, the results of this monitoring shall be
included in the calculation and reporting of the data submitted in the DMR.
c. Calculations for all limitations which require averaging of measurements shall utilize an
arithmetic mean unless otherwise specified by the Director in the permit..

Part Il
Page 13 of 14
6. Twenty-four Hour Reporting
a. The permittee shall report to the central office or the appropriate regional office any
noncompliance which may endanger health or the environment.. Any information shall be
provided orally within 24 hours from the time the permittee became aware of the
circumstances. A written submission shall, also be provided within 5 days of the time the
permittee becomes aware of the circumstances. The written submission shall contain a
description of the noncompliance, and its cause; the period of noncompliance, including exact
dates and times, and if the noncompliance has not been corrected, the anticipated time it is
expected to continue; and steps taken or planned to reduce, eliminate, and prevent reoccurrence
of the noncompliance..
b. The following shall be included as information which must be reported within 24 hours under
this paragraph:
(1) Any unanticipated bypass which exceeds any effluent limitation in the permit.
(2) Any upset which exceeds any effluent limitation in the permit.
(3) Violation of a maximum daily discharge limitation for any of the pollutants listed by the
Director in the permit to be reported within 24 hours.
c. The Director may waive the written report on,a case -by -case basis for reports .under paragraph
b. above of this condition if the oral report has been received within 24 hours.
7. Other Noncompliance
The permittee shall report all instances of noncompliance not reported under Part II. E. 5 and 6. of
this permit at the time monitoring reports are submitted. The reports shall contain the information
listed in Part II. E. 6. of this permit.
8. Other Information
Where the permittee becomes aware that it failed to submit any relevant facts in a permit
application, or submitted incorrect information in a permit application or in any report to the
Director, it shall promptly submit such facts or information.
9. Noncompliance Notification
The permittee shall report by telephone to either the central office or the appropriate regional
office of the Division as soon as possible, but in no case more than 24 hours or on the next working
day following the occurrence or first knowledge of the occurrence'of any of the following:
a. Any . occurrence at the water pollution control facility which. results in the discharge of
significant amounts of wastes which are abnormal in quantity or characteristic, such as the
dumping of the contents of a sludge digester; the known passage of a slug of hazardous substance
through the facility; or any other unusual circumstances.
b. Any process unit failure, due to known or unknown reasons, that render the facility incapable of
adequate wastewater treatment such as mechanical or electrical failures of pumps, aerators,
compressors, etc.
c. Any failure of a pumping station, sewer line, or treatment facility resulting in a by-pass
directly to receiving waters without treatment of all or any portion of the influent to such
station or facility.

Part II
Page 14 of 14
rtin such occurrences by telephone shall also file a written report in letter form within
Persons re P° g
5 days following first knowledge of the occurrence.
10. Availability of Revorts
er NCGS
a)(2) or Section 308 of the
Except
for data determined to be confidential andcordance w th the(terms shall be.avai able for
Federal Act, 33 USC 1310 all reports prepared in ac
ublic inspection at the offices of the Division ofWater making any false statement statement Act, effluent such
P �
data shall not be considered confidential. alKnowingly
rt ma result in the imposition of criminal penalties as provided for in NCGS 143-215.1(b)(2) o
repo Y
in Section 309 of the Federal Act.
11. Penalties for Falsification of _Reports
any
false
nt
The Clean Water Act provides that any person heT documenit submitted or required to
be
representation, or certification in any record or of
iance or
maintained under this permit, in cludin niched b monitoring a fine of reports
more reports
$10,000 per lviolation,
noncompliance shall, upon conviction, be pu Y
than two years per violation, or by both.
or by imprisonment for not more

PART III
OTHER REQUIREMENTS
A. Construction
No construction of wastewater treatment facilities or additions to add to the plant's treatment
capacity or to change the type of process utilized at the treatment plant shall be begun until Final
Plans and Specifications have been submitted to the Division of Water Quality and written approval
and Authorization to Construct has been issued.
B. Groundwater Monitoring
The permittee shall, upon written notice from the Director of the Division of Water Quality, conduct
groundwater monitoring as may required to determine the compliance of this NPDES permitted
facility with the current groundwater standards.
C. Changes in Discharges of Toxic Substances
The permittee shall notify the Permit Issuing Authority as soon as it knows or has reason to believe:
a.That any activity has occurred or will occur which would result in the discharge, on a routine or
frequent basis, of any toxic pollutant which is not limited in the permit, if that discharge will
exceed the highest of the following "notification levels'
(1) One hundred micrograms per liter (100 ug/1);
(2)Two hundred micrograms per liter (200 ug/1) for acrolein and acrylonitrile; five hundred
micrograms per liter (500 ug/1) for 2.4-dinitrophenol and for 2-methyl-4.6-dinitrophenol; and
one milligram per liter (1 mg/1) for antimony;
(3) Five (5) times the maximum concentration value reported for that pollutant in the permit
application.
b. That any activity has occurred or will occur which would result in any discharge, on a non -routine
or infrequent basis, of a toxic pollutant which is not limited in the permit, if that discharge will
exceed the highest of the following "notification levels';
(1) Five hundred micrograms per liter (500 ug/1);
(2) One milligram per liter (1 mg/1) for antimony; ,
(3) Ten (10) times the maximum concentration value reported for that pollutant in the permit
application.
D. Requirement to Continually Evaluate Alternatives to Wastewater Discharges
The permittee shall continually evaluate all wastewater disposal alternatives and pursue the most
environmentally sound alternative of the reasonably cost effective alternatives. If the facility is in
substantial non-compliance with the terms and conditions of the NPDES permit or governing rules,
regulations or laws, the permittee shall submit a report in such form and detail as required by the
Division evaluating these alternatives and a plan of action within sixty (60)'days of notification by the
Division.

PART IV
ANNUAL ADMINISTERING AND COMPLIANCE MONITORING FEE
REQUIREMENTS
A. The permittee must pay the annual administering and compliance monitoring fee
within 30 (thirty) days after being billed by the Division. Failure to pay the fee in
a timely manner in accordance with 15A NCAC 2H .0105(b)(4) may cause this
Division to initiate action to revoke the permit.

Michael F. Easley
Governor
o'G. Ross, Jr., Secretary
14C DEPT. OF ENV1RO7W0'qn
NCDENR Nrth Carolinagq -.E
EpAiArggrfJ_1qf; b3vf11JlMFA and Natural Resources
MOORESVILLE
. _.- . - "rGtCE
' Kerr T. Stevens, Director
Ms. Pamela Edwards
Hill Haven Residential Care, Inc.
114 Hill Haven Road
Statesville, North Carolina 28677
Division of Water Quality
April 2, 2001 -APR 0 9 2001
�6&21U
MI WA
Subject: NPDES Permit Modification
Permit NCO045012
Hill Haven WWTP
Iredell County
Dear Ms. Edwards:
The Division received, and - reviewed the request submitted by your ORC to modify the_sbbj.ecrpermit. We.have
no objection to his request. :This permit modification changes the samplefrequency for temperature -,from. daily to -
weekly'.
.,,,,.,ease uen page.,.The :remised page S e
d into your..
:t - permit.-T c.oldpageniay:then:.be,discarded',iAHother ,terins.'�nd,cohditionscontairiedin thp 6rigirial permit remain.
,
9 ;"This permit mo & i icajoniissued un efthe­­
requirements 6 ;,:��t
Statutes 143-215J �and, the.Merribranddin of Ag re mefttbe'twde:d, North CaiohnAand-Jhe;U.SEnVironmentaL:
1
otection ­P­rh-Agei-inc
y
If any parts, measurement frequencies or sampling requirements contained in tivs peiriiit"'modificaiti6n are
unacceptable to you,,you have. the right to. an adjudicatory..hearing.upon written requestwithin.thirty (30) days
following receipt of this letter. This request must be a written petition conforming to Chapter 150B of the North
Carolina General Statutes, 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.
If you have any questions concerning this permit modification, please contact Charles Weaver at [phone],
extension 511.
Sincerely,
aa;�
err T. Stevens
cc: Central Files
Mooresville Regi�5ndl-Offi—ce, Water-Qu - allty Section —
Point
Source Compliance Enforcement
NPDES Unit
Overcash Environmental Services
1617 Mail Service Center, Raleigh, Noah Carolina 27699-1617 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer VISIT US ON THE INTERNET@ http://h2o.enr.state.nc.us/NPDES

Permit NCO045012
A. (1.) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS
During the period beginning on the effective date of the 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:
EFFLUENT CHARACTERISTICS
LIMITS
MONITORING=REQUIREMENTS
Monthly,,
Average
Daily
' n-Maximum•_.._Frequency..,,,:
Measurement
Sample Type:
Sample Locat'iorii ,
Flow
0.018 MGD
Weekly
Instantaneous
Influent or Effluent
BOD, 5 day (202C)
30.0 mg/L
45.0 mg/L
2/Month
Grab
Effluent
Total Suspended Residue
30.0 mg/L
45.0 mg/L
2/Month
Grab
Effluent
NH3 as N (April 1 — October 31)
9.4 mg/L
2/Month
Grab
Effluent
NHs as'N (November l — March 31)
30.0 mg/L
2/Month'
Grab
Effluent,
Fecal Coliform.(geometric mean)
200/100 ml
400/100 ml
2/Month'' : ,.
_: Grab
Effluent
:Total Residual Chlorine
"
21Week'
Grab
'Effluerif . ':•
Temperature (°C) �` °'
Weekly'
Grab
Efflueritl-
Total Nitrogen
(NO2+NO3+TKN)
Quarterly
Grab
' `, Effluent
Total Phosphorus
Quarterly
Grab :
Effluent
pH1
2/Month
Grab
Effluent
Footnotes:
1.. The pH shall not be less than 6.0 standard units nor greater than 9.0 standard units.
There shall be no discharge of floating solids or visible foam in other than trace amounts.

SOC PRIORITY PROJECT: Yes Now_ m
To: Permits and Engineering Unit
Water Quality Section
Attention: Charles H. Weaver, Jr.
Date: May 10, 1999
NPDES.STAFF REPORT AND RECOMMENDATION
County: Iredell
Permit No. NC0045012
MRO No. 99-081
PART I - GENERAL INFORMATION
1. Facility and Address: Hill Haven Residential Care, Inc.
1116 Dogwood Road
Statesville, North Carolina 28677
2. Date of Investigation: 05-10-99
3. Report Prepared By: G. T. Chen
4. Persons Contacted and Telephone Number: Mr. Jerry Rogers,
ORC; [phone]
5. Directions to Site: From the junction of Highway 21/115 and
Old Mountain Road (SR 1005) in Troutman, Iredell County,
itravel north on Highway 21/115 approximately 2.2 miles to the
junction with Hill Haven Road (SR 1381) on the left. The
nursing facilities are located in the northwest quadrant of
this junction on the right (north) side of Hill Haven Road.
6. Discharge Point(s). List for all discharge points:
Latitude: 350 441.4511 Longitude: 800 53' 44"
Attach a U.S.G.S. map extract and indicate treatment facility
site and discharge point on map.
USGS Quad No.: E 15 NW USGS Name: Troutman, NC
7. Site size and expansion are consistent with application?
Yes.
8. Topography (relationship to flood plain included): Hilly with
slopes of 3 to 15%.. The site is not in a flood plain.
ti

9. Location of nearest dwelling: Approximately 200 feet. °
10. Receiving stream or affected surface waters: Unnamed
tributary to Third Creek.
a. Classification: C
b. River Basin and Subbasin No.: Yadkin and 03-07-06
C. Describe receiving stream features and pertinent
downstream uses: The receiving stream appeared to be 8
to 10 feet wide with a good flow on the day of the
inspection. Downstream uses are typical of agricultural
and secondary recreation.
PART II - DESCRIPTION OF DISCHARGE AND TREATMENT WORKS
1. a. Volume of wastewater to be. permitted: 0.018 MGD
(Ultimate Design Capacity)
I
b. What is the current permitted capacity of the wastewater
treatment facility? 0.018 MGD.
C. Actual treatment capacity of the current facility
(current design capacity)? 0.018 MGD.
i
d. Date(s.) and construction activities allowed by previous
Authorizations to Construct issued in the previous two
years: None.
e. Please provide a description of existing or substantially
constructed wastewater treatment facilities: The
existing facility consists of two septic tanks, two
surface sand filters in parallel, and effluent
chlorination. The combined flow is 18,000 GPD and is
discharged via a single outfall line. (Currently only
one septic tank system is in operation.)
f. Please provide a description of proposed wastewater
treatment facilities: N/A.
g. Possible toxic impacts to surface waters: There is a
discharge of wastewater disinfected by chlorine.
h. Pretreatment Program (POTWs only): N/A.
NPDES Permit Staff Report
Version 20192
Page 2

2. Residuals handling and utilization/disposal scheme: °
a. If residuals are being land applied, please specify
DWQ Permit No.: N/A
Residuals Contractor: N/A
Telephone No.: N/A
b. Residuals stabilization: PSRP: N/A
RFRP: N/A
Other: N/A
C. Landfill: N/A
d. Other disposal/utilization scheme (specify): Sludge is
removed as often as necessary by Lentz Septic Tank
Service (Lentz) in Statesville and disposed at a land
application site (Site No. 49-03) under Permit No. 00147,
issued by the Division of Environmental Health to Lentz.
3. Treatment plant classification (attach completed rating
sheet): Class I (no rating change, no rating sheet attached)
4. SIC Code (s) : 8051
Wastewater Code(s):
Primary: 11 Secondary:
Main Treatment Unit Code: 44013
PART III - OTHER PERTINENT INFORMATION
1. Is this facility being constructed with Construction Grant
Funds or are any public monies involved (municipals only)?
N/A.
2. Special monitoring or limitations (including toxicity)
requests: N/A. `
3. Important SOC, JOC or Compliance Schedule dates: (please
indicate) N/A.
4. Alternative Analysis Evaluation: Has the facility evaluated
all of the non -discharge options available? Please provide
NPDES Permit Staff Report
Version 10192
Page 3

regional perspective for each option evaluated. No b
alternative analysis evaluation was provided.
Spray Irrigation: N/A
Connection to Regional Sewer System: N/A
Subsurface: N/A
Other Disposal Options: N/A
5. Air Quality and/or Groundwater concerns or hazardous waste
utilized at this facility that may impact water quality, air
quality or groundwater? The existing discharge is totally
domestic and the facility does not use any hazardous waste.
There are no known air quality or groundwater concerns. Since
wastewater is disinfected by chlorine, possible toxic impact
to receiving stream may be a concern.
6. Other Special Items: None.
PART IV - EVALUATION AND RECOMMENDATIONS
It is recommended that the NPDES Discharge Permit be renewed
as requested by the applicant.
Signature of Report Preparer
Z),
Water Quality Re
Date
NPDES Permit Staff Report
Version 10192
a.1 Supervisor
Page 4

��sC�fa�e Fc,nITROUTMAN QUADRANGLE
NORTH. CAROLINA
I7.5 MINUTE SERIES (TOPOGRAPHIC)
Jew
v5
4 5'
m
q Z
low
,E l.511W

State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Wayne McDevitt, Secretary
Kerr T. Stevens, Director
Ms. Pamela Edwards
Hill Haven Residential Care, Inc.
1116 Dogwood Road
Statesville, North Carolina 28677
Dear Ms. Edwards:
I
I /V""ff
April 29, 1999
` AS I �c.
• 0a
CD"ERTMENT R
1 \ ,.. �, _NORTH CAROLINOF
�..,,... �.7 ".
ENVIRQNM1 ENT:'A'ND'NATUR?,:L'- ESOURCES
.f�4�'S�R!rt..lJ'�.:.�•��dty S'4..:i it: i]1���'.:...L�J '
1AY z_' 1999
Subject: NPDES Permit Renewal Application
Permit NCO045012
Hill Haven Residential Care, Inc.
Iredell County
. The Division received your permit renewal application on April 12, 1999. Thank you for
submitting this package in a timely fashion.
The permit renewal for this facility will be assigned to a member of the NPDES Unit staff.
That staff member will contact you if further information is needed to complete the permit
renewal. I regret to inform you that we have lost several staff members in the past few months -
the NPDES Unit currently has four vacant positions. This staff shortage is causing delays in our
processing of permit renewals. Our remaining staff are currently reviewing Authorizations to
Construct, speculative limit requests, major permit modifications and 201 plan reviews ahead of
permit renewals. This is necessary due to a variety of factors, including mandatory deadlines in
the statutes which govern our program.
If this staff shortage delays reissuance of NC0045012, the existing requirements in your
permit will remain in effect until the permit is renewed (or other action is taken by the Division).
We appreciate your patience and understanding while we operate with diminished resources. If
you have any additional questions concerning renewal of the subject permit, please contact me at
[phone], extension 511.
Sincerely,
Charles . Weaver, Jr.
NPDES Unit
cc: IMooresville Regional_Office,-Water -Quality Section, -
NPDES File
P.O. Box 29535, Raleigh, North Carolina 27626-0535 919 733-5083, extension 511 (fax) 919 733-0719
An Equal Opportunity Affirmative Action Employer [e-mail]

1. .1:1
• � {ti �
.\
.. ` \i � `�. �.
�;;.J? � .,- r

HILL HAVEN RESIDENTIAL CARE, INC.
C/O PAMELA EDWARDS
1116 DOGWOOD ROAD
STATESVILLE NC. 28677
Home Phone [phone]
April 08, 1999
Charles Weaver
NPDES Unit
NC DNER
P.O. Box 29535
Raleigh, North Carolina 27626-0535
Dear Mr. Weaver:
Per our telephone conversation today, I am requesting renewal of- Hill. Haven's
NPDES Permit NC0045012.
Please find enclosed the completed application with the copies required for renewal.
Please be advised that Lentz Septic 'tank Service is retained yearly for sludge removal.
This application has been prepared by Pamela Edwards, the Permittee of the permit and
the President of the corporation.
Sincerely,
Pamela Edwards
President
Enclosures: (3)

`i
n0N ,' Slim
1 $®R1V1 1J
IT APFLICA <1 MGD fiow) .
filed only by gers °f 1`° domestic wastewater
�To be Resources
y4. C. Deparbnent of Environment and Natural turUnit • .
rivision of water QuaW3 , :
t P.O.13ox 29p RaDeigh, NC 27626.p535
' '1
�...._.u.,.-,............NPDES Permit Number NC00,
North CarOUna ,:�:y:...:F _F� 7 e .
..... ••<(loovvnj.':.,.... rt. ::; Please or type
IL. Mailing address of applicant:
•, ' .: , , ; .. t � i =�,.^•.•, o� �. �• � ti'► r� e_n�r �. Cap Z
Facility Name
Owner- Name;
Street Address
City
State
ZIP Code
,Telephone Number
Fax Number
e-mail Address
2. Location of facility producing discha.rge:
.. = N-ame- if-'di:fferent-from above)
Facility Contact Person'
Street Address or State Road
;City / Zip Code
County .
Telephone Number
•
,. .. _. cation:
3. Reason for app ,: •. ••
E ansion/Modification Existing Unpermitted.Discharge
� �'" New Facility
Renewal
Please provide a description of the expansion/modification:
A. D�escriation'of _the existing twat ent facilities (Dist all installed components witD capacities):
Version 9197
Page 1 of 2

,,, 1 9-

TROUTMANQUADRANGLE �g,�,�y�`
HILL HAVEN NURSING HOME NORTH CAROLINA
NCO045012 MINUTE SERIES (TOPOGRAPHIC)
UNNA TRMTJTARY TO THIRD allMK
5101: 11440000 FEET 511 80*52'30
7-35*45'
o
ii
730000
FEET
'Mkl k, N55
V
I 811E�,
q
f
50
L
`LN
m
n52
42'30"
15 1� NW
,.?ram �/� C,,''
)A
I

` Permit No. NCO045012
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
DIVISION OF.ENVIRONMENTAL MANAGEMENT'
PERMIT
TO DISCHARGE WASTEWATER UNDER THE
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,
Hill Haven Skilled Nursing Home and Rest Home, Inc
is hereby authorized to discharge wastewater from a facility located at
Hill Haven Nursing Home
Hill Haven Road( NCSR 1381)
Barium Springs
Iredell County
to receiving waters designated as an unnamed tributary to Third Creek in the Yadkin -Pee Dee River
Basin"
in accordance with effluent limitations, monitoring requirements, and other'conditions set forth in
Parts I, II, and III hereof.
This permit shall become effective
This permit and the authorization to discharge shall expire at midnight on July 31, 1999
Signed this day
E�VLROISF�1.
XUN
A. Preston Howard, -Jr., P.E., Director
01§10 .aF EQVIRONmEyTAL Division of Environmental Management
4?QQRES{f/l!E 9EG�QI yI RiAFJAGE4 By Authority of the Environmental Management Commission

Permit No. NC0045012
SUPPLEMENT TO PERMIT COVER SHEET
Hill Haven Skilled Nursing Home and Rest Home, Inc
is hereby authorized to:
1. Continue to operate an existing 0.018 MGD wastewater treatment facility consisting of two
septic tanks with two surface sand filters and effluent chlorination located at Hill Haven Nursing
Home, Hill Haven Road ( NCSR 1381 ), Barium Springs, Iredell County (See Part III of this
Permit), and
2; Discharge from said treatment works at the location specified on the attached map into an
unnamed tributary to Third Creek which is classified Class C waters in the Yadkin -Pee Dee
River Basin.

DISCHARGE POINT .TROUTMAN QUADRANGLE
HILL HAVEN NURSING HOME NORTH CAROLINA
NCO045012 MINUTE SERIES (TOPOGRAPHIC) 16�
UNNAMED TRIBUTARY TO THIRD CREEK 80*52'30"
55' 510: 11 440 000 FEET Sill
—35*45'
goo ` ry'v �� = r• 0 �� `•I t""'� 1.
1V
11\11uj
j
730 000
—
ellll�i✓-FEET
-"55
eat
/L
45
95C
tn
vy
3954
p
of
3953 V) Sil
ZZZZ:
Ij
II
II
o
R)
/-1 di
0
f ya 3952
42'30"
NW
3951
•
Cos

EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS SUMMER (April
1- October 31) Permit:No.
NCO045012
During the period beginning on the effective date of the permit and lasting until expiration, the Permittee is authorized
to discharge from
outfall(s) serial number 001.
Such discharges shall -be limited and monitored by the permittee as specified below:
,Effluent Characteristics
Discharge Limitations
Monitoring Requirements
Measurement
Sample. *Sample
Monthly AM Weekly Avg, Daily Max
Freouency
IY" Location
PiQW
0.018 hm
Weekly
Instantaneous
I or E
:BOD, 5 day, 20°C
30.0 mg/l� 45.0 mg/I
2/Month
Grab
E
?6 al Suspended Residue
30.0 mg/I 45.0 mg'/I
2/'Month
Grab
E
NH3 as N
9.4 mg/I
2/Month
Grab
E
='acal Coliform (geometric .mean)
200.0 /100 ml 400.0 /100 ml
2/Month
Grab
E
Total Residual Chlorine
2/Week
Grab
E
Temperature
Weekly
Grab
E
*'Sample locations: E - Effluent, I - Influent
The pH shall not be less than 6.0 standard units nor greater than 9.0 standard units and shall be monitored 2/month at the effluent by grab
sample.
There shall.be no discharge of floating solids or visible foam in other. than trace amounts.

A. ().EFFLUENT LIMITATIONS AND. MONITORING REQUIREMENTS WINTER (November 1 - March 31) Permit No. Nf:0045012
During the period beginning on the effective date of the permit and lasting until expiration, the Permittee is authorized to discharge from
outfall(s) serial number 001. Such discharges shall be limited and monitored by the permittee as specified below:
EP�Auent Characteristics
Flmv
BOD, 5 day, 200C
dotal Suspended Residue
`iFl� as N
racai Coliform. (geometric mean)
Total Residual'. Chlorine
Temperature
Discharge Limitations
Monthly Avg., Weekly
Avg. Daily Max
0.018 NM
30.0-mg/i
45.0 mgil'
30.0 mg/I
-45.0 mg/I
30.0 mg/I
200.0 /100 ml
400.0 /100 ml
Monitoring
Requirements
.Measurement
Sample *Sample
Freguencv
Ly" Location
Weekly
Instantaneous
I or E
2/Month
Grab
E
2/Month
Grab
E
2/Month
Grab
E
2/Month
Grab
E
2/Week
Grab
E
Weekly
Grab
E
* Sample locations: E - Effluent, I- Influent
The pH shall not be less than 6.0 standard units nor greater than 9.0 standard units and shall be monitored 2/month at the effluent by grab
sample.
There shall be no discharge of floating solids or visible foam in other than trace amounts.

State of Borth Carolina
Department of Environment,
�1 Health and Natural Resources
SDivision of Environmental Management
kV James B. Hunt, Jr., .Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
Ms. Pamela Edwards
Route 16, Box 38
Statesville, NC 28677
Dear Mr. Edwards:
August 31, 1994
_ r
ram- 4- � .:
SEP 6 199,E
DIVISION OF ElIYIAONMENTAI MANAGEMENT
WOORES&LE REGIONAL OFFICE
Subject: Permit No. NCO045012
Hillhaven Nursing Home
lredell County
1n accordance with your application for discharge permit received on January 4, 1994, we
are forwarding herewith the subject state - NPDES 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 US Environmental Protection agency dated
December 6, 1983.
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, Post Office Drawer 27447, Raleigh, North
Carolina 27611 -7447. Unless such demand is made, this decision shall be final and binding.
Please take notice this permit is not transferable. Part II, EA addresses the requirements
to be followed in case of change in ownership or control of this discharge.
This permit does not affect the legal requirements to obtain other permits which may be
required by the Division of Environmental Management or permits required by the Division of
Land Resources, 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 Ms. Wilson at telephone
number 919/733-5083.
Sincer 1
Original ty nod By
David A. Goodrich
A. Preston Howard, Jr.
cc: Mr. Jim Patrick, EPA
_Mooresville Regi-nal Office
M
P.O. Box 29535, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
All e_yual 1N;w,..ii sp ni",i,,aii1's —H i t_n,Nivyoi 50% ieC'y'Gc1/ i0% jo5L wnSU,T,ei Napdi

Permit No. NC0045012
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAE RESOURCES
DIVISION OF ENVIRONMENTAL MANAGEMENT' ENT or
�NVTRONMEN'r, HEALTH,
O NATURAL RESOURCrS
PERMIT
TO DISCHARGE WASTEWATER UNDER THE SEP 6 199A
NATIONAL POLLUTANT DISCHARGE ELIMINATION 5,,,�TEf�
�J�au FU"" AENTAL MANAuE ,[jjT
93HESVRLE REGIONAL OFFICE
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,
Hill Haven Skilled Nursing Home and Rest Home, Inc
is hereby authorized to discharge wastewater from a facility located at
Hill Haven Nursing Home
Hill Haven Road ( NCSR 1381 )
Barium Springs
Iredell County
to receiving waters designated as an unnamed tributary to Third Creek in the Yadkin -Pee Dee River
Basin
in accordance with effluent limitations, monitoring requirements, and other conditions set forth in
Parts I, II, and III hereof.
This permit shall become effective October 1, 1994
This permit and the authorization to discharge shall expire at midnight on July 31, 1999
Signed this day August 31, 1994
Original Signed BY
pav-1d A. Goodrich
A. Preston Howard, Jr., P.E., Director
Division of Environmental Management
By Authority of the Environmental Management Commission

s
Pen -nit No. NC0045012
SUPPLEMENT TO PERMIT COVER SHEET
Hill Haven. Skilled Nursing Home and Rest Home, Inc
is hereby authorized to:
1. Continue to operate an existing 0.018 MGD wastewater treatment facility consisting of two
septic. tanks with two surface sand filters and effluent chlorination located at Hill Haven Nursing
Home, Hill Haven Road (NCSR 1381 ), Barium Springs, Iredell County (See Part III of this
Permit), and
2. Discharge from said treatment works at the location specified on the attached map into an
unnamed tributary to Third Creek which is classified Class C waters in the Yadkin -Pee Dee
River Basin.

DIS GE MINT .TROUTM
CHAR AN QUADRANGLE
HILL HAVEN NURSING HOME NORTH CARO*LINA b b
NCO045012 MINUTE SERIES (TOPOGRAPHIC)' Ice"'
M.
55' LJNNAMM TRIBUTARY TO THIRD CREEK 510; 11 440 000 -FEET 511, 80*52'30"
0 1 u(Il 35*45'
0
730 000
_EEET
P' k 1n 3955
d T's C:)
3954
r--\ ��53
SIM
k,
X
It
X), 93 II
3952
95V
tt
42'30"
91 lol- NW
3951
Y �IULW
(V/

A. ().EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS SUMMER (April 1 - October 31) Permit No. NCO045012
During the period beginning on the effective date of the permit and lasting until expiration, the Permittee is authorized to discharge from
outfall(s) serial number 001. Such discharges shall be limited and monitored by the permittee as specified below:
Effluent Characteristics
Flow
BOD, 5 day, 200C
Total Suspended Residue
NH3 asN
Fecal Coliform (geometric mean)
Total Residual Chlorine
Temperature
Discharge Limitations
Monthly Avg. Weekly Avg,
0.018 %M
30.0 mg/1
30.0 mg/I
9.4 mg/I
200.0 /100 ml
Monitoring
Reg-ulrements
Measurement
Sample
*Sample
Daily Max
Frequency
Type
Location
Weekly
Instantaneous
I or E
45.0 mg/I
2/Month
Grab
E
45.0 mg/I
2/Month
Grab
E
2/Month
Grab
E
400.0 /100 ml
2/Month
Grab
E
2/Week
Grab
E
Weekly
Grab
E
* Sample locations: E - Effluent, I - Influent
The: pH shall not be less than 6.0 standard units nor greater than 9.0 standard units and shall be monitored 2/month at the effluent by grab
sample.
There shall be no discharge of floating solids or visible foam in other than trace amounts.

A. (). EFFLUENT LIMITATIONS AND.MONITORING REQUIREMENTS WINTER (November 1 - March 31) Permit No. NCO045.012 F .
During the period beginning on the effective date of the permit and lasting until expiration, the Permittee is authorized to discharge from
outfall(s) serial number 001. Such discharges shall be limited and monitored by the permittee as specified below:
Effluent Characteristics
Flow
BOD, 5 day, 20°C
Total Suspended Residue
NH3 asN
Fecal Coliform (geometric mean)
Total Residual Chlorine
Temperature
Discharge Limitations
Monthly Avg, Weekly Avg,
0.018 MGM
30.0-•mg/I
30.0 mg/1
30.0 mg/I
200.0 /100 ml
Monitoring
Requirements
Measurement
Sample
*Samale
Daily Max
Frequency
Tune
Location
Weekly
Instantaneous
I or E
45.0 mgii `
2/Month
Grab
E-
45.0 mg/I
2/Month
Grab
E
2/Month
Grab
E
400.0 /100 ml
2/Month
Grab
E
2/Week
Grab
E
Weekly
Grab
E
* S ample locations: E - Effluent, I - Influent
Tho, pH shall -not be less than 6.0 standard units nor greater than 9.0 standard units and shall be monitored 2/month at the effluent by grab
sample.
There shall be no discharge of floating solids or visible foam in other than trace amounts.

FAK11
CE.-tion B. Schedule of Cemflliance
1. The permittee shall comply with Final Effluent Limitations .specified for discharges is
accordance with the followmS schedule:
perTrnee shall comply with Futal Effluent Urnitsdons by the effective date of the permit ttaless
specified below.
2. permittee shall at all times provide the operation and maintenance necessary to operate the
f existing facilities at optimum efficiency.
?. No later than 11 cale,.dar da�•s following a date identified in the above schedule of corripliarice,•
the permittee shall submit either a report of progress or, in the case of specific actions being
required by identified dates. it. written notice of compliance or noncompliance. In the litter
case. the notice shall include the cause of noncompliance, any remedial actions taken. and the
rroabilily of rneeting the next schcdii'e requirements.

PART II
STANDARD CONDITIONS FOR NPDES PF.R.tVIITS
� • •za ea•
The Director of the Division of Environmental Management.
2. DEN1 or Division
Mesis the Division of Environmental Managemrrst. Department of Environment, Health and
Natural Resources.
3. =C
Used herein mess the North Carolina Environmental Aanagement Commission.
4. Act or "the Act"
The Federal Water Pollution Control Act, also known as the Clean Water Act, as amended. 33
USC 1251, et. seq. .
3, 11�„�Da��lezr�L--mentrc
t: The "month];- average discharge" is defined as the total mass of all daily dischar es
sampled anl'or measured during a calendar month on which daily discharges are sampled
and measured, divided by the number of daily discharges sampled and/or measured during
such month. It is therefore, an arithmetic mean found by adding the weights of the
pollutant found each day of the month and then dividing this sum by the number of days
the tests %%ere reported. The limitation is identified as "Monthly Average" in Part I of the
permit.
b. The "we'ekly average discharge" is defined as the total mass of all daily discharges sampled
and/or measured during the calendar week (Sunday - Saturday) on which daily discharges
are sampled and measured, divided by the number of daily discharges sampled and/or
measured during such week. It is, therefore, an arithmetic mean found by adding the.
%%eights of pollutants found each day of the week and then dividing this sum by the
number of days the tests were reported. This limitation is identified as "Weekly Average"
in Part I of the permit.
c. The "maximum daily discharge" is the total mass (weight) of a pollutant discharged during
a calendar day. If only one sample is taken during any calendar day the weight of pollutant
calculated from it is the "maximum daily discharge." This limitation is identified as "Daily
Maximum," in Part I of the permit.
d. The. "average annual discharge" is defined as the total mass of all daily discharges sampled
and/or measured during the calendar year on which daily discharges are sampled and
memured, divided by the number of daily discharges sampled and/or measured during such
year. It is, therefore, an arithmetic mean found by adding the weights of pollutants found
each day of the yearand then dividing this sum by the number of days the tests were
reported. Thjs limtation is defined as "Annual Average" in Part I of the permit.
r;.
s;

6. ror:ert-ztion Memure`
a. The "average monthly concentration; other than for fecal coliform bacteria, is the sum of
the concentrations of all daily discharges sampled and/or measured during a calendar month
on which daily dischar es are sampled and measured, CAW by the number of daily
discharges sampled ancvor measured during such month (arithmetic mean of the daily
concentration values). The daily concentration value is equal to the concentration of a
composite simple oHn the case of grab samples is the arithmetic mean (weighted by flow
value) of all the samples collected during that calendar day. The average monthly count for
fecal coliform bacteria is the geometric mean of the counts for samples collected during a
calendar month. This limtation is identified as 'Monthly Average" under Other Limits' in
Part I.of the permit.
b. The *average weekly concentration," other than for fecal coliform bacteria, is the sum of the
• concentrations -of all daily discharges sampled and/or measured during a calendar week
(Sunday/Saturday) on which daily discharges are sampled and measured divided by the
number of daily discharges sampled and/or measured during such week (arithmetic mean of
the daily concentration values). The daily concentration value is equal to the concentration
of a composite sample or in the case of grab samples is the arithmetic mean (weighted by
flow value) of all the samples collected during that calendar day. The aerate weekly count
for fecal coliform bacteria is the 4eometric mean of the counts for samples collected during
a calendar week. This limitation is identified as 'Weekly Average' under 'Other Limits" b
Pi-t I of the permit.
e. The "maximum daily concentration" is the concentration of a pollutzrtt discharge during a
calendar day. If only one sample is taken during any calendar day the concentration of
p-llmam calculated from it is the "Maximum Daily Concentration'. It is identified as'_
"Dail Ma.-,imum" under "Other Limits" in Pitt I of the permit
d. The "jverare annual concentration," other than for fecal coliform bacteria, is the sum of the
concentrations of all daily discharges sampled and/or measured during a calendar year on
%%hick daily discharges are sampled and measured divided by the number of duly
discharges sampled and/or measured durin; such year (arithmetic mean of the daily
concentration values). The daily concentration value is equal to the concentration of a
composite sample or in the cue of grab samples is the arithmetic mean (vweighted by flow
value) of all the samples collected during that calendar day. The average yearly count for
fecal coliform bacteria is the geometric mean of the counts for samples collected during.a
calendar year. This limitation is identified as "Annual Average" under "Other Limits" in
Fart I of the permit. .
e. The "daily average concentration" (for dissolved oxygen) is the mi;nimurn allowable amount
of dissolved oxygen required to be available in the effluent prior to discharge averaged
over a calendar day. If only one dissolved oxygen sample is taken over a calendar day. the
sample is considered to be the "daily average concentration" for the discharge. It is
identified as "daily average" in the text of Part L
f. The "quLnerIv average concentration" is the average of all samples taken over a calendar
quarter. It is identified as "Quarterly Average. Limitation" in the text of Part I of the permit
g. A calendar quarter is defined as one of the following distinct periods: January through
March, Ar 0 through June, July through September, and October through December.

7. �hrr,fez��rtmrnts
"1
a. Flow. (!►1GD): The flow limit expressed in this permit is the 24 hours average flow,
averaged monthly. It is determined as the arithmetic mean of the total daily flows recorded
during the calendar month.
b. An "instantaneous flowmeasurement" is a measure of flow taken at the time of:arapling,
when both the sample, and flow will be representative of the total dischug-e-
e. A "continuous flow- measurement" is a measure of discharge flow from the facility. hich
occurs continually without interruption throughout the operating hours of the facility. Flow
shall be monitored continually except for the infrequent times when there may be no flow
or for infrequent maintenance activities on the flow de%im
a. Tmnc of Sa_-=Ie ,
a. Composite Sample: A composite sample shall consist of:
(1) eriod of
discharge of
fagnd combined collected
toilthtime
t to of flow measured as over a 24 tthetime of
ds g proportional
individual sample collection, or
(2 ) a series of grab samples of equal volume collected over a 24 bout period %ith the time
intervals between samples determined by a preset number of gallons passing- the
sa:;.rling point., Flow measurement between sample intervals shall be determined by
use of a flow• recorder and totalizer, and the present gallon interval between sample
collection fixed at no greater than U24 of the expected total daily flow at the treatment .
system. or
(3) a sin£'.e, continuous sample collected over a 24 hour period proportional to the rate of
flow.
In accordance with (1) above, the time interval between influent grab samples shall be. no
greater than once per hour, and the time interval between effluent grab samples shall be no
greater than once per hour except at wastewater treatment systems having a detention time
of Treater than 24 hours. In such cases; effluent. grab samples may be collected it time
intervals evenly spaced over the 2s hour period which are equal in number of hours to the
detention time of the system in number of days. However, in no case may the time interval
betty een effluent grab samples be greater than six (6) hours nor the number of samples less
than four (4) during a 24 hour sampling period.
b. Grab Sample: Grab samples are individual samples collected over a period of time not
exceeding 15 minutes; the grab sample can be taken manually. Grab samples must be
rcgr esentative, of the discharge or the receiving waters.
9. Czt:ujat3on of MearL '
a Arithmetic Mean: The arithmetic e n of arch ideal vset of values is the summation of the
individual values divided by the numb
b. Geometric Mean: The geometric mean of any set of values is the Nth root of the product of
the individual values where N is equal to the number of individual values. The geometric �
nean is equiValent to the antilog of the arithmetic mean of the logarithms of the individual •.
%values. Tot purposes of calculating the geometric mean, values of tern (0) shall be
eo::siI:red to be one p).

C. weighted by Flow Value: Weighted by flow value means the summation of each
eoncentrstion times its respective flow divided by the summation of the respective flows.
10. ��t.•,�a• Day
A calendar day is defined as the period from midnight of one day until midnight of the next
day. Howeeiveer�e r purposes of this permit, any consecutive 24-hour period that reasonably
represents radar azy may be used for sampling.
11. lHux dons Substance
A hazardous substance means any substance designated under 40 CFR Part 116 pursuant to
Section 311 of the Clean Water Act.
12. Te-de Pollutant
A toxic pollutant is any pollutant listed as toxic under Section 307(&)0) of the.Clean Water Act.
SECTION B GENER.&I CON'D1TI-O�-S
The permittee must comply with all conditions of this permit. Any permit noncompliance .
constitutes a violation of the Clean Water Act and is grounds for enforcement action; for pe'rrtsit
termination, revocation and reissuance. or modification; or denial of a permit renewal .
a� = Iiration. ""
a. The permittee shall comply with effluent standards or prohibitions established under
section 307(a) of the Clean Water Act for toxic pollutants and with standards for sev►•a e
sludge use or disposal established under section 405(d) of the Clean Water Act within the
time provided in the regulations that establish these standards or prohibitions orstandards
for se -a -age sludge use or disposal, even if the permit has not yet been modified to
rorate the requirement.
b. The Cie= Water Act provides that any person who violates a permit condition is subject to
a civil penalty not to exceed S25,000 per day for eachviolation. Any person who
ntiligently violates any permit condition is subject to criminal penalties of S2,500 to
S25,000 per day of violation, or imprisonment for not more than 1 year, or both. Alt}�
person who knowingly violates permit conditions is subject to criminal penalties of $S,
to S50,000 per day of violation, or imprisonment for not more than 3 years, or both. Also,
any person who violates a permit condition may be assessed an administrative penalty not
to exceed S10,000 per violation with the maximum amount not to exceed S125,000. [Ref:
Section 309 of the Federal Act 33 U.S.C.1-319 and 40 CFR 122.41(a)]
e. Under state law, a .civil penalty of not more than ten thousand dollars (S10,000) per:
violation may be assessed against any person who violates or fails to act in accordance with
the.terms, conditions, or requirements of a permit. [Ref: North Carolina General Statutes
143.215.6A]
d. Any person may be assessed an administrative penalty by the Administrator for violating
se:tion 301, 302, 306, 30:', 303, 318, or 405 of the Act, or any permit condition or
limitation implementing any of such sections in a permit issued under section 402 of the
Act. Administrative penalties for Class I violations are not to exceed S10,000 per violation.
With the maximurri spec —it of any Class I penalty assessed not to exceed S25,000.

rapt . of let
Penalties for Class Il vioIitions are not to exceed 510,000 per day for each day during- +�
which the violation continues, R-ith the maximum amount of any. Class U penalty not to
exceed S1:5,000.
2• Du
The perminee shall take all reasonable steps to minimize or prevent any discharge or sludge use
or disposal in violation of this permit which has a reasonable likelihood of adversely affecting
human health or the environment.
3. QN-11 cd CriMIM-1 Liability
Except as provided in permit conditions on -Bypassing- (Put 11, C-4) and 'Power Fu'hms'
(Part 11. C•7), nothing in this permit shall be construed to relieve the ppermittee from any
responsibilities, liabilities, or penalties for noncompliance pursuant to NCGS 43-rn'3eui�s
215.6 or Section 309 of the Federal Act. 33 USC 1319. Furthermore, thep .. .
responsible for consequential damages, such as fish kills, even though the responsibility for
effective compliance may be temporarily suspended.
4. Oil 14:22•600 512h5l'."ce Liability
!�ot.'tirg in this pe.-mit shall be construed to preclude the institution of any legal action or relieve
the perrrunee from any responsibilities, liabilities. or, penalties to which the permittee is or may
be subjen to under NCGS 143.215.75 et seq. or Section 311 of the Federal Act, 33 VSG 1321.
Funherore, the perrrinee is responsible for consequential damages, such as fish kills. even
though the respomibilit}• for effective compliance may be temporarily suspended.
The issuance of this permit does not convey any property rights in either real or personal
propern.. or any exclusive privileges, nor does it authorize any injury to private property or any
Invasion of personal rights, nor any infringement of Federal, State or local laws or regulations.
6. orZ! +r• or Offshore Constructim
This permit does not authorize or approve the construction of any onshore or offshore physical
structures or,facilities or the underulang of any work in any navigable waters.
7. Severay'
The provisions of this permit are severable, and if any provision of this permit, or the
application of any provision of this permit to arty circumstances, is held invalid, the application
of such provision to other circumstances, and the remainder of this permit, shall not be affected
thereby.
S. Duty to Provide Informati0�
The pernittee shall furnish to the Permit issuing Authority, within a reasonable time, any
infornnat,on which the Permit Issuing Authority may request to determine whether cause exists
for mod:f�ing. re�ol;.ing and reissuing, or terminating thus permit or to determine compliance
with this permit: The permittee shall also furnish to the Permit Issuing Authority upon
request. comes of records required to be kept by this permit.

�• 9. •D�lt�w 1-,
If the perrrm ttee wishes to continue an activity regulated by this permit after the expiration date
of this permit. the porn i ue must apply for and obtain a new penrvt
30. Exriratien of Permit
The permittee is not authorized to discharge after the expiration date. In order to receive
automatic authorization to'discharge beyond the expiration date, the pennittee shall submit such
information., forms, and fees as are required by the agency authorized to issue permits no later
than 180 days prior to the expiration date. Any permin that his not requested renewal at least
180 days prior to expiration. or any perminee that does not have a permit after the expiration
and has not requested renewal at least 180 days prior to expiration, will subject the petmunee to
enforcement procedures as pro-vided in'NCGS 143.215.6 and 33 USC 1251 et. 589.
11. Srn tot:• Re ;wire_
All applications, reports, or information submitted to the Permit Issuing Authority shall be
signed and certified.
a. All permit applications shall be signed as follows:
(1) ' For a corporation: by a responsible corporate officer. For the purpose of this Section.
a responsible corporate officer means: (a) a president, secretary, treasurer or vice
president of the corporation in charge of a principal business function, or any other
person a ho performs similar policy or decision making functions for theeorporation. .
or (b) the manager of one or more manufacturing production or operating facilities
ern -loving more than 250 persons or having gross annual sales or expenditures
exceeding 25 million (in second qquamer'1960 dollars), if authority to sign documents
,has been assigned or deletated to the manager in accordance with corporate procedures.
(2) Fora partnership or sole proprietorship: by a general partner or the .proprietor.
respectively; or
(3) For a municipality, State, Federal, or other public agency: byeither a principal
exe:utive officer or ranking elected official.
b. All rep-.ns required by the permit and other information requested by the Permit Issuing
Authority shall be signed by a person described above or by a duly authorized
representative of that person. A person is a duly authorized representative only if:
p) The authorization is made in writing by a person described above;
(2) The authorization specified either an individual or a position having responsibility for -
the overall operation of the regulated facility or activity, such as the position of plant
manager, operator of a well or well field, superintendent, a position of equivalent
responsibility, or an individual or position having overall reskonsibtlity for.
environmental matters for the company.-. (A duly authorized representative may'thus be
either a named individual or any individual occupying a named position.), and
(3) The Krittert_authorization is submitted to the Permit Issuing Authority.

c. Certification. Any person signing a document under paragraphs A. or b. of this section
shall make the following certification: t,
I certify, under penalty of law, that this document and all stuchments were prepared under
my direction or supervision in accordance with a system designed to assure that qualified
personnel properly gather and evaluate the information submitted. Based on my inquiry of
the person or persons who manse the system, or those persons directly responsible for
gathering the Information, the inorntation submitted is, to the best of my knov►•ledge and
belief, we, accurate, and complete. I am aware that there are significant penalties for
submitting false information, including the possibility of fines and imprisonment for
knowing violations'
This permit may be modified, revoked and reissued, or terminated for cause. The filing of a
request by the perminee for a permit modification, revocation and reissuance, or termination.
or a notification of planned changes or anticipated noncompliance does ttiot stay any permit
condition.
The issuance of this permit does not prohibit the permit issuing authority from reopening and
modifying the permit, revoking and reissuing the permit, or terrrunating the permit as allowed
by the laws. rules, and regulations contained in Title 40, Code of Federal Regulations. Parts
122 and 123; Title 1SA of the 'North Carolina Administrative Code, Subchapter 2H .0100; and
North Carolina General Statute 143.215J et. al.
14. previc-ut Permits
All previous National Pollutant Discharge Elimination System Permits issued to this facility.
whether for operation or discharge, are hereby revoked by issuance of this permit. [The
exclusive authority to operate this facility arises under this permit. The authority to operate the
facility under previously issued permits bearing this number is no longer effective. j The
conditions, requirements, terms, and provisions of this permit authorizing discharge under the
National Pollutant Discharge Elimination System govern discharges from this facility.
`��T10� C. OPERATION a+'�'D,lA1`TE� 4\'CE OF POLLttTlO,* *CONTROLS
1, e-sifted O;g,, ator
Pursuant to Chapter 90A.44 of North Carolina General Statutes, and upon classification of the
facility by the Certification Commission, the permittee shall empI.oy a certified wastewater
treatment plant operator in responsible charge (ORC) of the wastewater treatment facilities.
Such operator must hold a certification of the grade equivalent to or treater than. the
classification assigned to the wastewater treatment facilitiesby the Certification ComrnisPion.
The permiree must also employ a certified back-up operator of the appropriate type and any
grade to comply with the conditions of Title 1 SA, Chapter 8A .0202. The ORC of the facility
must.visit each Class I facility at Ieast weekly and each Class II,111, and IV facility at least
daily, excluding weekends and holidays, and must properly manage and document daily
operation and maintenance of the facility and must comply with all other conditions of Title
ISA, Chapter BA .0202. Once the facility is classified, the.perminee shall submit a letter to the
Certification Commission which designates the operator in responsihl; charge within thirty
dati-s after the wastewater treatment facilities are SOr complete.

......
Pape S of 14
The permittee shall at all times properly operate and maintain all facilities And systems of
treatment and control (and related appurtenances) which art installed or used by the pesmittee to
Achieve compliance with the conditions of this permit. Proper operation and maintenance also
includes adequate laboratory controls and appropriate quality assurance procedures. This
Provision requires the operation of back-up or auxiliary fatuities -or similar systems which are
installed by a ernumee only when the operation is necessary to achieve compliance v►ith the
conditions of the perrWL
It shall not be a defense, for a permittee in an enforcement action that it would have been
necessary to halt or reduce the permitted activity in order to maintain compliance with the
condition -of -this permit. -
4. P%:;&tcir; of Treatment Facilitie%
.a. Definitions
(I) 'Bj-pass" means the known diversion of waste streams from any portion of a.tre>ltment
facility including the collection system, which is not a designed or established or
operating mode for the facility.
(2) "Severe property damage' means substantial physical damage to property; damage to
the treatment facilities which causes them to become inoperable, or substantial and permanent loss of natural resources which can reasonably be expected to occur in the
absence of a bypass. Severe property damage does not mean economic loss caused by
delays in production.
b. Bypus not exceeding limitations.
The perrrittee may Allow any bypass to occur which does not cause effluent limitations to
be exceeded, but only if it also is for essential maintenance to assure efficient operation.
These bypasses are not subject to the provisions of Paragraphs e. and- d. of this section.
C. !notice
0) Anticipated bypass. If the permittee knows in advance of the need for a bypass, it
shall submit prior notice, if possible at least ten days before the date of the bypass;
including an e%-a)uation of the anticipated quality and affect of the bypass.
t -
I (?) Unanticipated bypass. The perrtvttee shall submit notice of an unanticipated bypass as
required in Part I1,-E. 6. of this permit.- (24 hour notice).
d. Prohibition of Bypass
p) Bypass is prohibited and the Permit Issuing Authority may take enforcement action
against a per *nee for bypass, unless:
(A) Bypass was unavoidable to prevent loss of life, personal injury or severe property
damage;
(B) .There w ere no., feasible alternatives to the bypass, such as the u,e ,f auxiliary
trealment fac:lities, retention of untreated wastes or maintenance during normal

periods of equipment downtime. This condition is not satisfied if adequate backup �
equipment should have been installed in the exise ercof reasonable engineering
ds of equipment
judgment to prevent a bypass which occurred during normal Ppne
downtime or preventive maintenance; and
(C) The perminee submitted notices as required under Paragnph c. of this section.
(2) The Permit Issuing Authority may approve an anticipated bypass, after considering its
adverse affects, if the Permit Issuing Authorit%• determines that it will meet the three
conditions listed above in Paragraph d. p) of this section.
s. LTA
a. Definition.
"Upset " means an exceptional incident in which there is unintentional and temporary
noncompliance with �technolog v based permit effluent limitations because of factors
i
beyond the reasonable control of the permittee. An upset does not include noncompliance
to the extent caused by operational error, improperly designed treatment facilities.
inadequate treatment facilities, lack of preventive maintenance, or careless or improper
operation. '
b. Effect of an upset.
liance %ith
An 'Upset constitutes an affirmative defense to an action
buuernht for ertts of paragraph c. of this
such technology based permit effluent limitations if the requirements
condition are met. No determinatieand before made durinin action for noncompladministrative review �ance�msfiinal .
non:otnplian:e was caused by ups1
is
administrative action subject to judicial review.
e. Conditions ne:essary for a demonstration of upset.
A permittee %%-ho wishes to establish the affirmative defense of upset shall demonstrate,
through properl)- signed, contemporaneous operating logs, or other relevant evidence that:
(1) An upset occurred and that the perminee can identify the cause(s) of the upset;
(2) The perrtvttee facility was at the time being properly operated; and
(3) The perrnJuee submitted notice of the upset as required in Part 1I, E. 6. (b) (B) of this
pem-It.
(4) The perntittee complied with any remedial measures required under Part 11, B. 2. of this
pernut. .
d. Burden of proof.
In any enforcement proceeding the pennittee seeking to establish the occurrence of an upset
has the burden of proof.
6. $erne�ea e�rst3ncss
S%lids. slud:es, filter backer ash, liz other ais pollutants
in accord nce aoved in t th NCGS 1a3e course of i215.1 and in
control of �t ast_�� aters shent Or
all be utt p
a manner such a.� to prey ent any pol'.L�ta�nt from such materials from entering waters of the Stars
or navisable waters of the United States. The permittee shall comply With all existing federal

regulations governing the disposal of sewage sludge. Upon pprornuIgation of 40 CFR Part 503.
anv permit issued by the Perrrut Issuing Authority for the uts7iutiorddisposal of sludge rasa}• be
��an
40
ed and modified, or revoked and reissued, to incorporate applacable requirements Stanarsfor
he
$03. The permitter shall comply with applicable 40 CFR Pact time
Standards for the
Use and Disposal of Sewage Sludge (when promulgated) within the time prodded in the
regulation, even if the t is not modified to incorporate the requirements The f dispPeftosal
shaft aotify the Permit Issuing Authority of any significant change in its sludge use or deposal
practices.
7, power Failures .
The permittee is responsible for maintaining adequate safeguards as requited by DEINi
Retulation, Title 15A, North Carolina Administrative Code, Subchapter 2H, .0124 Relsabilft .
to prevent the discharge of untreated or inadequately
a er jounces, standby generatortreated wastes s electrical on retention of
ff
failures either by means of alternate p
inadequately treated effluent.
1. R��rec•�t2tive Sze; inQ
Samples collected and measurements taken, as required herein, shall be characteristic of the
volume and nature of the permined discharge. Samples collected at a frequency less than daily
shall be mken on a day and time that is characteristic of the discharge over the entire period
vrhich the sample represents: All samples shall be taken at the monitoring points -specified in
this permit and, unless otherwise specified, before the effluent joins or is diluted by any other
Wa';tesire am, body of water, or substance. Monitoring points shall not be changed without
notification to and the approval of the Permit Issuing Authority.
2. RansiLtr
�\1onitoring results obtained during the previous month(s) shall be summarised for each month
and reported on a monthly- Discharge Monitoring Report (I)MR) Form (DEM To. MR 1.11.2.
:1 or altemati\e forms approved by the Director, DEM, postmarked no later than the 30th dad'
followins the completed reporting period.
The first D\JR is due on the last day of the month following the issuance of the permit or in the
case of a new facility, on the last day of the month following the commencement of discharge.
Duplicate signed copies of these, and all other reports required herein, shall be submined to the
following address:
Division of Environmental Management
Water Qualiq• Section
ATTE.'TION: Central Files
Post Office Box 29533
Raleigh, North Carolina 27626-0S35
3. Flon- M l uremem
AFt ropriate flow measurement devices and methods consistent with Accepied scientirle
j prankes shall be selected and used to ensure the accuracy and reliability of measurements of
i the volune of monitored discharges. The devices shall be installed, calibrated and maintained
to ensure that the accuracy of the measurements are consistent with the accepted capability' of
that t%pe of de%•ice. Devices selected shall be capable of measuring flows with a maximum
deviation of less than + 10`ic from the true dischrge rates throughout the range of expected

discharge volumes. Once -through condenser cooling water flow• which is monitored oy pump,
logs, or pump hour meters as specified in Part I of this permit and based on the n mufacturei s
pump curves shall not be subject to this requirement. el
Test procedures for the analysis of pollutants shall conform to the EMC tegulations published
pursuant to KCGS 143-215.53 et. seq, the Water and Air Quality Reportin Acts. and to
regulations published pursuant to Section 304(g), 33 USC 1314,. of the federal Water
Pollution Control Act, as Amended, and Regulation 40 CFR 136; or in the cue of sludge use or
disposal, approved under 40 CFR 136, unless otherwise specified in 40 CFR 503, unless
other test procedures have been specified in this permit.
To meet the intent of the monitoring *requiired by this permit, all test procedures must produce
minimum detection and reporting levels that are below• the permit discharge requirements and
all data generated must be reported down to 'the minimum detection or lower reporuntlevel of
the procedure. If no approved methods are determined capable of achieving minimum
detection and reporting levels below, permit discharge requirements, then the most sensitive
(method with the lowest possible detection and reporting level) approved method must be used.
S. PenaYes for TL-n=zing
The Clean Water Act provides that any person who falsifies, tampers with, or knowingly
renders inaccurate, any monitoring device or method required to be maintained under this
permit shall, upon conviction. be punished by a fine of not more than S10,000 per violation. or
by imprison -rent for not more than two years per violation, or by both. If a conviction of a
person is for a violation committed after it first conviction of such person under this paragraph.
punishment is a fine of not more than S20,000 per day of violation, or by imprisonment of not
more than 4 ;'ears, or both.
6. Re.-C-L" Retention
Except for records of monitoring information required b;- this permit related to the perrriittee'S
seu-sle sludge use and disposal activities, which shall be retained for a period of at least five
years (or longger as required by 40 CFR 503), the permittee shall _retain records of aU
monitoring information, including all calibration and maintenance records and all original strip
chart recordings for continuous monitoring instrumentation, copies of all reports required by
this permit, for a period of at least 3 years from the date of the sample, measurement, report
or application. This period may be extended by request of the Director at any time.
7. Recordnc Results
For each measurement or sample taken pursuant to the requirements of this permit, the
permittee shall record the following information:
a. The date. exact place, and time of sampling or measurements;
b. The individual(s) who performed the sampling or measurements;
e. The dates) analyses were performed;
d. The ihdi%-idua](s) who performed the analyses;
e. The ira1vtica] techniques or methods used; and
f. The results of such analyses.

. f. umectien a_n� Emu
The perrrittee shall allow the Director, or an authorized representative (Including an authorized
contractor Acting .a% a representative of the Director), upon the presentation of credentials and
other documents as may be required by la' to; '
A. Enter upon the perntitteels premises where a regulated facility or activity is located or
conducted, or where records must be kept under the conditions of this permit;
b. Have access to and copy, at reasonable times, any records that must,be kept Studer the
conditions of this peraut;
C. Inspect at reasonable times any facilities, equipment (including monitoring and control
equipment), practices, or operations regulated or required under this permit; and
d. Sample or monitor at reasonable times. for the purposes of assuring permit compliance or
as otherwise authorized by the Clean Water Act, any substances .or parameters at any
location.
1. Chanee in Diecha_•�e
All dischsges authorized herein shall be consistent with the terms and conditions of this
remit.* The. discharge of any pollutant identified in this permit more frequently than or at a
level in excess of that authorized shall constitute a violation of the permit.
2. plarined Chip
The permittee shall give notice to the Director as soon as possible of any planned Physical
alteratiors or additions to the permitted facility. Notice is required only when: .
a. The alteration or addition to a permitted facility may meet one of the criteria for determining
. %% hether a facilit;• is a ne%%- source in 40 CFR part 122.29 (b); or
b. The alteration or addition could significantly change the nature or increase the quantity of
pollutants discharged. This notification appplies to pollutants which are subject neither to
effluent limitations in the permit. nor to nouficztion requirements under 40 CFR Put M2.42
(a) 0). .
c. The alteration or addition results in a significant change in the permittee's sludge use or
disposal practices, and such alternation, addition or change mayjustif}• the applicationof
permit conditions that are different from or absent in the existing permit, including
notification of additional use or disposal sites not reported during the permit application
process or not reported pursuant to an approved land application plan.
3. Arili; iFated Voncompliance
The perrninee shall give advance notice to the Director of any planned changes in the permitted
facility or acti%•ity Which may result in noncompliance with permit requirements.

4.
This permit is not transferable to any person except afier notice to the Director. The Director •,
may require modification or revocation and reissuance of the perminee and incorporate such
other requirements as may be necessary under the Clean Water Act- -
./ • f -MAT-T".11
Monitoring results shall be reported at the intervals specified elsewhere in this Prnnit
a. Monitoring results must be reported on a Discharge Monitoring Report (D.NS) (See Part If.
D. 2 of this permit) or forms provided by the Director for reporting results of monitoring of
sludge use or disposal practices.
b. If the permittee monitors any pollutant more fmiuently than required by the permit. using
test procedures specified in Part II. D. 4. of this permit or in the case of sludge use or
disposal, approved under 40 CFR 503, or as specified uu this pe=t, the results of this
monitoring shall be included in the calculation and reporting of the data submitted in the
D.MR.
C. Calculations for all limitations which require averaging of measurements shill utilise as
arithmetic mean uriless otherwise specified by the Director in the permit.
6. Twenty-four Hour Re; in
a. The perminee shall report to the central office or the appropriate re Tonal "office any
noncompliance which may endanger health or the environment. Any information shall.be
provided orally within 24 hours from the time the permittee became aware of the
circumstances. A wrinen submission shall also be provided within S days of the time the
permittee becomes aware of the circumstances. The written submission shad contain a
description of the noncompliance, and its cause; the period of noncompliance, including
exact dates and times, and if the noncompliance has no been corrected, the. anticipated time
it is expected to continue; and steps taken or planned to reduce. eliminate, and prevent
reoccurrence of the noncompliance.
b. The following shall be included as information which must be reported within 24 hours
under -this paragraph:
(1) Any unanticipated bypass which exceeds any effluent limitation in the permit.
r) Any upset which exceeds any effluent limitation in the permit
(3) Violation of a maximum daily discharge limitation for any of the pollutants listed by the
Director in the permit to be reported within 24 hours..
C. The Director may waive the written report on a case -by -case basis for reports under
piasraph b. above of this condition if the oral report has been received within 24 hours.
7. Other Soncompliance
The perminee shall report all'instances of noncompliance not reported under Part 13. E. S and 6.
of this permit at the time monitoring reports are submitted. The reports shall contain the
information listed in Part II. E. 6. of this permit.

�J I NI • �l •
Where the permittee becomes aware that it failed to submit any relevant facts in a permit
application, or submitted incorrect information in a permit application or in any report to the
Director, it shall promptly submit such facts or information.
9, Notification
The permittee shall report by telephone to either the antral office or the appropriate regional
office of the Division as soon as possible, but in no case more than 24 hours or on the next
working day following the occurrence or first knowledge of the occurrence of any of the
foIlovring:
a. Any occurrence at the water pollution control facility which results in the discharge of
sig;tficant amounts of wastes which are.abnormal in quantity or characteristic, such as the
dumping of the contents of a sludge digester; the known.passage of a slug of hazardous
substance through the facility; or any other unusual circumstances.
b. Any process unit failure, due to known or unknown reasons, that render the facility
incapable of adequate wastewater treatment such as mechanical or electrical failures of
pumps, aerators, compressors, etc.
c. Any failure of a pumping station, sewer line, or treatment facility resulting in a by-pass
direct]v to receiving waters without treatment of all or any portion of the influent to such
su:ion or 4 ility.'
Persons reponing such occurrences by telephone shall also file a written report in letter forts
wiw.in S days following first knowledge of the occurrence.
10. ,��',�'�''i1i•�• of Re,,4orts
Except for data determined to be confidential under NCGS 143.215.3(a)(2) or Section 309 of
the Federal Act, 33 USA 1318, all reports prepared in accordance with the terms -shall be
s%ailable for public inspection at the offices of the Division of Environmental 'Management. As
Ziuired by the Act, effluent data shall not be considered confidential.'Knowingly making any'
statement on any such repon may result in the imposition of criminal penalties as provided
for in NCGS 143•215.1(b)(2) of in Section 309 of the Federal Act.
11. F�al:ies fcrFals'fication ofRefllorts
The Clean Water Act provides that. any person who knowingly mikes any false statement,
representation, or certification to any record or other document submitted or required to be
maintained under this permit, including monitoring reports or reports of compliance or
noncompliance shall, upon conviction. be punished by a fine of not more than S10,000 per
violation, or by imprisonment for not more than two years per violation, or by both.

PART III
OTHER REQUIREMENTS
No construction. of wastewater treatment facilities or additions to add to the plant's treatment
capacity or to change the type of 'process utilized at the treatment plant shall be begun. until
Final Plans and Specifications have been submitted to the Division of Environmental
Management and written approval and Authorization to Construct, has been issued.
The permittee shall, upon written notice from.the Director of the Division of Environmental
Management, conduct groundwater monitoring as may be required to determine the
compliance of this NPDES permitted facility with the current groundwater standards.
FeWIT-2—Nm
The permittee shall notify the Permit Issuing Authority as soon as it knows or has reason to
believe:
a.That any. activity has occurred or will occur which would result in the discharge, on a
routine or frequent basis, of any toxic pollutant which is not limited in the permit, if that r
discharge will exceed the highest of the following "notification levels";.
(1) One hundred micrograms per liter (100 ug/1);
(2)Two hundred micrograms per liter (200 ug/1) for acrolein and ac-ylonitrile; five
hundred micrograms per liter (500 ug/1) for 2.4-dinitrophenol and for 2-methyl-4.6
dinitrophenol; and one milligram per liter (1 mg/1) for antimony;
(3) Five (5) times the maximum concentration value reported for that pollutant in the
permit application.
b. That any activity has occurred or will occur which would result in any discharge,.on a
non -routine or infrequent basis, of a toxic pollutant which is not limited in the permit, if
that discharge will exceed the highest of the following "notification levels";
(1) Five hundred micrograms per liter (500 ug/1);
(2) One milligram per liter 0 mg/1) for antimony;
(3) Ten (10) times the maximum concentration value reported for that pollutant in the
permit application.
D. Requirement to Continually Evaluate Alternatives to Wastewater Discharges
The permittee shall continually evaluate all wastewater disposal alternatives and pursue the
most environmentally sound alternative of the reasonably cost effective alternatives: If the
facility is in substantial non-compliance with the terms and conditions of the NPDES permit
or governing rules, regulations or laws, the permittee shall submit a report in such form and
detail as required by the Division evaluating these alternatives and a plan of action within
sixty (60) days of notification by the Division.

PART IV
ANNUAL ADMINISTERING AND COMPLLANCE MONTrORING FEE REQUIREMENTS
A. The permittee must pay the annual administering and compliance monitoring fee within 30
(thirty) days after being billed by the Division. Failure to pay the fee in a timely manner in
accordance with 15A NCAC 2H .0105(b)(4) may cause this Division to initiate action to
mvoke`the permit.

�tiee�
'SOC PRIORITY PROJECT: Yes No X
If Yes, SOC No.
'To: Permits and Engineering Unit
Water. Quality Section
Attention: Susan A. Wilson
Date: January 19, 1994
NPDES STAFF REPORT AND RECOMMENDATION
County: Iredell
Permit No. NCO045012
PART I - GENERAL INFORMATION
1. Facility and Address: Hill Haven Nursing Home WWTP
Route 16, Box 38
Statesville, North Carolina 28677
2. Date of Investigation: 01-14-94�
3. Report Prepared By: G. T. Chen
4. Persons Contracted and Telephone Number: Mr. Tim Stevenso ,
Maintenance.Supervisor; [phone]
5. Directions -to Site: From the junction of Highway 21/115 an
Wagner Street (SR 1303) in Troutman, Iredell County, travel
north on Highway 21/115 approximately 3.00 miles to the
junction. with Hill Haven Road (SR 1381) o the left T_h
nursing facilities are located in the ort s quadrant f
this junction on the right (north) side ad.
6. Discharge Point(s). List for all discharge points:
Latitude: 35° 44' 45" Longitude: 80' 53' 44"
Attach a U.S.G.S. map extract and indicate treatment facility
site and discharge point on map.'
USGS Quad No.: E 15 NW USGS.Name: Troutman, NC
7. Site size and expansion are consistent with application?
Yes X No If No, explain:
8. Topography (relationship to flood plain included): Hilly with
slopes of 3 to 15%. The -site is not in a flood.plain.
9. Location of nearest dwelling: Approximately 200 feet.

10. Receiving stream or affected surface waters` Unnamed
tributary to Third Creek.
a. Classification: C
b. River Basin and Subbasin No.: Yadkin and 03-07-06
C. Describe receiving stream features and pertinent
downstream uses: The receiving stream appeared to be 8
to 10 feet wide with a good flow on the day of the
inspection. Downstream users are unknown.
PART II.- DESCRIPTION OF DISCHARGE AND TREATMENT WORKS
1. a. Volume of wastewater to be permitted: 0.018 MGD
(Ultimate Design Capaci,ty)
b. What is the current permitted capacity of the wastewater
treatment facility? 0.018 MGD.
C. Actual treatment capacity of the current facility
(current design capacity)? 0.018 MGD.
d. Date(s) and construction activities allowed by previous
Authorizations to Construct issued.in the previous two
years: None.
e. Please provide a description of existing or substantially'
constructed wastewater treatment facilities: The
existing facility consists of two septic tanks, two
surface sand filters, and effluent chlorination. The
combined flow is 18,000 GPD and discharged via a single
outfall line.
f. Please provide a description of proposed wastewater
treatment facilities: N/A.
g. Possible toxic impacts to surface waters: None.
h. Pretreatment Program (POTWs only): N/A.
in development: approved:
should be required: not needed:
2. Residuals handling and utilization/disposal scheme:
a. If residuals are being land applied, please specify DEM
i
Permit No.:
Residuals Contractor:
Telephone No.:
NPDES Permit Staff Report
Version 10/92 -
Page 2

b. Residuals stabilization: PSRP:
RFRP:
Other:
c. Landfill:
d. Other disposal/utilization scheme (specify): Sludge is
removed as often as necessary -by Lentz Septic Tank
Service in Statesville and disposed to a land application
site (Site No. 49-03) under Permit No. 00147 issued by
the Division of Environmental Health.
3. Treatment plant classification (attach completed rating
sheet): Class I, see attached rating sheet.
4. SIC Code(s): 8051
Wastewater Code(s) of actual wastewater, not particular
facilities, i.e., non -contact cooling water discharge from a
metal plating company would be 14, not 56.
Primary: 11 Secondary:
Main Treatment Unit Code: 44003
PART III - OTHER PERTINENT INFORMATION
1. Is this facility being constructed with Construction Grant
Funds or are any public monies involved (municipals only)?
N/A.
2. Special monitoring or limitations (including toxicity)
requests: N/A.
3. Important SOC, JOC or Compliance Schedule dates: (please
indicate) N/A.
Date
Submission of Plans and Specifications
Begin Construction
Complete Construction
4. Alternative Analysis Evaluation: Has the facility evaluated
all of the non -discharge options available. Please provide
regional perspective for each option evaluated. No
alternative analysis evaluation is given.
Spray Irrigation:
NPPES Permit Staff Report
I
Version 10/92 -
Page 3
I
I
j

Connection to Regional Sewer System:
Subsurface:
Other Disposal Options:
5. Air Quality and/or Groundwater concerns or hazardous waste
utilized at this facility that may impact water quality, air
quality or groundwater? The existing discharge is totally
domestic and the facility does not use any hazardous waste.
No air quality, groundwater, and/or water quality is adversely
impacted by the discharge.
6. Other Special Items: None.
PART IV - EVALUATION AND RECOMMENDATIONS
It is recommended that the NPDES Discharge Permit be renewed
as requested by the applicant.
Signatur of Report Preparer
Water Quality RegiWal Supervisor
Date
NPDES Permit Staff Report
versi on 10192
Page 4

55' ' i 508
T �/ ROUTMAN QUADRANGLE
piSUW2 �D,A� NORTH CAROLINA �CP��PS�I
7.5 MINUTE SERIES (TOPOGRAPHIC) v5
STATESVILL-1 2.5 MI. 5101 11440 000 FEET 5111 80 ° 52'30"
35°45'

' RATING SCALE FOR CLASSIFICATION OF FACILITIES
Name of Plant:
Owner or Contact Person:L—AIWO19'
Mailing Address: �! ,� )/1 bm.
— A4 LC 1,0b
z�
County:-VX/6-// Telephone.:��[f.Z -i O
NPDES Permit .No. NCOOLD/ Nondisc.
Per. No. _
IssueDate: (, Expiration'.
Date: 9
Existing Facility New Facility
Rated By: 1 Date:
Reviewed (Train. & Cert.) Reg. Office
Reviewed (Train. & 'Cert.) Central Office
ORC ��rnrrvY1i-P� Grade
Plant Class: (circle one) �I� II III
IV Total Points
REM POINTS (5) SECONDARY TREATMENT UNITS
(a) Carbonaceous Stage
(1)
Industrial Pretreatment Units and/or
(i)Aeration - High Purity Oxygen System ... :.
20
Industrial Pretreatment Program
Diffused Air System :..........
10
(see definition No. 33) 4
Mechanical Air System (fixed,
(2)
_ DESIGN FLOW OF PLANT IN GPD
floating or rotor) ..............
8
(not applicable to non -contaminated cooling waters, sludge
Separate Sludge Reaeration .....
3
handling facilities for water. purification plants, totally .
(ii) Trickling Filler
closed cycle systems (def. No. 11), and" facilities
High Rate ...................
7
consisting only of Item (4) (d) or Items (4) (d) and (11) ('
0 - 20.000........ ..... ...... 1
Standard Rate ....... ........
Packed Tower
5
5
20,001 -- 50,000 ........ ........:....
.
t i i Biolo � � � e
( ) gcal Aerated Filter or Aerated
50,001 — 100.000................... ..... 3
Biological Filter-.,...
10
100,001 — 250,000 ............. ..... ..... 4
(iv) Aerated lagoons ...................
10
250,061 — 500,000.......................... 5
500.001--1,000,000 ........ _ ............... 8
(v) Rotating Biological Contactors ........
10
1,000.001 -- 2,000.000 ........................ 10
2.000,001 (and up) - rate 1 point additional for each
(vi) Sand 'Filters-
200,000 gpd capacity up to a
maximum of 30
intermittent biological .....
recirculating biological .... .
Design Flow (gpd) f g DDD
(vn) Stabilization Lagoons ................
S
(3)
PRELIMINARY UNITS (see definition no. 32)
(viii)Clarifier ..............................
5
-
(a) Bar Screens....... .... ................. 1
(ix) Single stage system for combined
or
carbonaceous removal of BOD'and
(b) Mechanical Screens, Static Screens or
nitrogenous removal by nitrification .
Comminuting Devices .. ................... 2
(see def. No. 12) .(Points for this. item
(c) Grit Removal ................................ 1
have to be in addition to items (5) (a)
or
O through (5) (a) (vir7 ..................
8
(d) Mechanical or Aerated Grit Removal .. _ ..-:..... 2
(x) Nutrient additions to' enhance BOD
(e) Flow Measuring Device ....................... 1
removal .................................
or
(xi) , Biological Culture ('Super Bugs') addition
(f) Instrumented Flow Measurement .............. 2
to enhance organic compound removal .....
5
(g) Preaeration................................ 2
(b) Nitrogenous Stage
(i) Aeration- High Purity'Oxygen System .....
20
(h) Influent Flow Equalization .... .......... 2
Diffused Air System ...........
10
O Grease or Oil Separators - Gravity .......... 2
_ Mechanical Air System (fixed,
Mechanical .......... 3
floating, or rolorf ...... ......
8
Dissolved Air Flotation. 8
Separate Sludge Reaeration .....
3
.0) Prechlorination .............................. 5
(ii) Trickling Filter
..te
tan Rate .dard
(4)
PRIMARY TREATMENT UNITS
Septic Tank definition 43) 0
.. • ...... • .
StanRate
S
�......
5
5
(a) (see no. ..............
Packed Tower .. • . • •
5
(b) Imhoff Tank .... ° .:............... .............. 5
(iii) Biological .Aerated Filter or Aerated
(c) Primary Clarifiers ................. .......... 5 _
Biological Filter ................:.........
10
(d) Settling Ponds or Settling Tanks for Inorganic
(iv) Rotating Biological Contactors..........:..
10
Non -toxic. Materials (sludge handling facilities
(v) Sand Filter -
for water purification plants, sand, gravel,
intermittent biological ........
2
stone, and other mining operations except
recirculating biological ........
3
recreational activities such as gem or gold
(vi) Clarifier .................................
5
mining) ...................................... 2

TERTIARY OR ADVANCED TREATMENT UNIT
(10) CHEMICAL ADDITION SYSTEM (S) (See definition No. 9)
(6)
(a) Activated Carbons Beds -
(not applicable to chemical additions rated as Item'
Without carbon regeneration ............:..... 5
(3) 0). (5) (a) (xi. (6) (a). (6) (b). (7) (b). (7) (e).
with carbon regeneration .................... 15
(9) (a). (9) (b). or (9) (c) 5 points each: UsL-
Powdered or Granular Activated Carbon Feed -.
..... 5
(b)
without carbon regeneration ................. 5
..... 5
with carbon regeneration .................... 7 5
..... 5
....... ............:...... 5
(c) Air Stripping ...............................
.:... 5
(d) DenitrificationProcess (separate process) . .. 10
(e) Electrodialysis .............................. 5
(11) MISCELLANEOUS UNITS
(� Foam Separation :............................ 5
(a) Holding Ponds, Holding Tanks or Settling Ponds
(g) Ion Exchange ................................ 5
for Organic or Toxic Materials Including wastes
(h) Land Application of Treated Effluent
from mining operations- containing nitrogen and/or
(see definition no. 22b), (not applicable for
phosphorous compounds in amounts significantly
sand, -gravel, stone and other similar- mining
greater than Is common for domestic wastewater .......... 4
operations)
(b) Effluent Flow Equalization (not applicable to storage
(i) on agriculturally managed sites (See def.
basins which are inherent in land application systems). 2
No. 4) ................................... 10
(c) Stage Discharge (not applicable to storage basins
QQ by high rate infiltration on non -agriculturally
inherent in land application systems___—. 5
managed sites (includes rotary distributors
(d) Pumps,_ 3
and similar fixed nozzle systems) ... ......... 4
(e) Stand -By Power Supply_ 3
(iii) by subsurface disposal (includes low pressure
"(f) Thermal Pollution Control Device.__--..-_-._-._..._....._. 3
pipe systems and gravity systems except at
plants consisting of septic tank and nilrifica-
TOTAL POINTS 1�-
tion lines only) .................. _ ......... 4
(7 Microscreens .................................... 5
(j) Phosphorus Remo,ral by Biological Processes
CLASSIFICATION
(See def. No. 26) ............................ 20
(k) Polishing Ponds - without aeration ....... 2
P
5 - 25 Points
ki,26- 50 Points
with aeration .......... 5
1.._
(I) Post Aeration - cascade .............. 0
diffused or mechanical ... 5
Class III.____ 51- 65 Points
Class IV. 66- Up Points
(m) Reverse Osmosis........ ....................... 5
Sand or Mixed -Media Filters - low rate ........... 2
Facilities having a rating of one through four points, inclusive.
(n)
high rate .......... 5
do not require a certified operator. Classification of all other
(o) Treatment processes for removal of metal or
facilities requires a comparable grade operator in responsible
cyanide .................................... 15
charge.
(p) Treatment processes for removal of toxic
materials other than metal or cyanide ......... 15
Facilities having an activated sludge process will be assigned
a minimum classification of Class 11.
I SLUDGETREATMENT
Facilities having treatment processes for the removal of metal
(a) Sludge Digestion Tank - Heated ............... 15 or cyanide will be assigned a minimum classification of Class It.
Aerobic...._..........
Unheated .............
3 Facilities having treatment processes for. the biological removal
(b) Sludge Stabilization (chemical or thermal) .......
5 of phosphorus will be assigned a minimum classification of Class
(c) Sludge Drying Beds - Gravity.... ....._.....
2
Vacuum Assisted .......
5
(d) Sludge Eluldation ...............................
5 In -plant processes and related control equipment which are an
(e) Sludge Conditioner (chemical or thermal) ........
5, integral part of industrial production shall not be considered waste
(1) Sludge Thickener (gravity) ......................
5 treatment. Likewise, discharges of wastewater from residences
(g) Dissolved Air Flotation. Unit
having a design flow of 1.000 gpd or less. shall not be subject to
(not applicable to a unit rates as (3) n . .......
B rating.
(h) Sludge Gas Utilization (including gas storage) ....
2
(i) Sludge Holding Tank- Aerated ................
5 ADDITIONAL COMMENTS:
Non -aerated ............
2
(11 Sludge Incinerator - (not including activated
carbon regeneration) - -
10
(k) Vacuum Filter. Centrifuge or Filter Press or other
similar dewalering devices ....................
10
(8) SLUDGE•OISPOSAL (including'incinerated ash)
(a) Lagoons .....:..................................
(b) Land -Application (surface and subsurface)
(see definition 22a)
-where the facility holds the land app. permit ...
10
-by contracting to a land application operator who
02
holds the land application permit ...............
-land application of sludge by a contractor who does
not hold the permit for the wastewater treatment
facility where the sludge is generated .........
10
(c) Landfilted (burial) •.............................
5
(9) DISINFECTION
Chlorination...... ....................
l;,J
(a)
(b) Dechicidnateon ........................
5
(c) Ozone ...... ..........................
S -
(d) Radiation ............................

,.State ofNorth Carolina
Department of Environment,
k
I Health and Natural. Resources
Division of Environmental Management
V
. ,tames B. Hunt, Jr., Governor
ff
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
l -
Pamela Edwards, Administrator -
Hill Haven Skilled Nursing Home
Route 16, Box 38
Statesville, NC 28677
Dear Ms. Edwards:
January 4; 1994
. N.C. HEFT. OF
&3Pd`JIRONMENJ', YIEALTP
& NtI-ITURAL RESOURCES
C`i JP�,.,c5
DIVISION OF EfTVIR014 ETAL E,4 P;{iCE i
. VIOORESViLLE MIOIAL
Subject: NPDES Permit Application.
Permit No. NCO045012
Hill Haven WWTP
Iredell County
This letter is to acknowledge the receipt of payment of $200.00 and a permit renewal request
for the subject facility.
This application has been assigned to Susan A. Wilson (919-733-5083) of our Permits and
Engineering Unit for review. You will be advised of any comments, recommendations,
questions or other information necessary for the review of the application. A cursory review
indicates that a residuals management plan has not been submitted. If the application is not
made complete within thirty days, it will be returned to you and may be resubmitted when
complete.
I am, by copy of this letter, requesting that our Regional Office Supervisor prepare a staff
report and recommendations regarding this discharge. If you have any questions regarding
this application, please contact me at the number listed above.
Sincerely,
4'
Susan A. Wilson
Environmental Engineer
cc: IMo resyille RegionaleOffice
Permit File
-P.O. Box 295A, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post -consumer paper

VV
H ,LL Aa/.�N SKILLED NURSING HOME AND REST HOME.
A r ROUTE. 16; BOX 3E
STATESVI,LLE. NORTH CAROLINA 28677 ' 66 2�
PHONE [phone] OR 872-7602
-December 20, 1993-
Ms. Colleen Sullins, P. E. �7'�Y�`s 7"i "�-'ia�� T-IR-L'iIT
& I,4.ATtir;l;L %L���J?i L:i
Permits and Engineering Unit -
Division of Environmental Management ��
P. 0. Box 29535
Raleigh,'N. C. 27626-0535
OIU!5f0^; OF
Re: NPDES Permit # ITC0045012 �OpRk�VaLLE OEG1011kI CAME'
Iredell County
Dear Ms. Sullins
Please be advised that I am requesting renewal of Hill Haven's
NPDES permit.
You will find enclosed the completed application form, submitted
in triplicate, and a check in the amount�of $200.00, for the
processing fee.
Hill Haven's wastewater treatment facility consists of two
septic tanks, two surface sand filters, and tablet -type effluent
_chlorination. The sand in the filter beds is leveled and
raked regularly; all weeds and vegetation is kept out of the_
sand beds. The sand is tilled every six months and new - sand
is added as needed. The pipes are"level.ed and cleaned.every
six months.
Thank you for your assistance regarding.this matter.
Sincerely,
Pamela Edwards
Administrator
Enclosures (4)

— _. urn
`IIIORTH CAROLINA DEPT. OF NATURAL RESOURCES AND C0jWK_I_ ,KVELOpMEt�iT:' 7
ENVIRONMENTAL MANAGEMENT COMMISSION
NATIONAL POLLUTANT 'DISCHARGE ELIMINATION SYSTEM :;- r;-}�.�� u;_�
APPLICATION FOR PERMIT TO DISCHARGE • SHORT FORM G �`'''' ' r' � ti : A►►liU11GN1 IUMbIR
AGENCY
C °
USE
10 be filed Deify by services. wholesale and ►etail trade, atE RECEIVEn
andother comi.erciai establishments including vessels 1 7—
WEAR �., DAY
0o not attempt to complete this form without reading the accompanying Instructions
Please Print or type .
1. Name. address. and telephone number of facility producing discharge
A. Name 411 140 en SkoolPa A)Q9iCevv. ` ie
t't(1 [t1C (s � PC� 4i71M 1° =110
d. Street address a + e, II.
C. City 0. State _- ° �•
E. County 4-e,4,,i1
G. Telephone No. r 0 �1__ 0
Area
Code
2. Sic
(Leave blank)
�. Number of employees
d. Nature. of business — L zyN%
S. (a) Check here if discharge occurs 411 year . or
(b) Check the months) discharge occurs:
1. 0 January 2.0 February S.O Barth 4.0 Apri1 5.0 fty
6. a June 7. O July B. a August ox September 10. 0 October
11. 0liovee+ber 12.0 Do comer
(c) Mow many days per week:
1.01 2.932.3 3.0 4-S 4.O'6.7
G. Types of waste water discharged to surface waters only (check.as applicable)
Oischarge per
operating day
A.. Sanitary. daily
average
g. Cooling water. etc.,
daily average
C. Other discharge(s),
daily average;
specify.
D. MAiimum per operat-
ing day force-bined
discharge (all types)
Flow, gallons per operating dey
Volume treated before
discharging (percent-)
0.7-999 iQ06-1999 Sd00-S499 10.000. 50.000 None 0.1• 30- 6S- . 9S.
44•999 or more 29.9 64.9 94.9 100
(1) (2I (3) (4)
3- iron
. - A.

T. If any of the types of waste identified in it" i, either treated or am -
treated. are disCAarged to places other than surfaceesters. chock below
Of applicable.
Waste water is discharged to:
0:1 d!!
(1)
1000-11!!11
ft)
l000-!!!! •
(3)
10.000-11.!!!
fdl
50.000 er g"
IS)
A. NMILIPAI te+w-r, tystar
N, 1Nrrs rgr aiuel owl l
'
C. septir•tank
D. Evaporation lagoon or pond
. Other, specify:
a.--ouk,"ro-f� epirate discharge-gClets: - - - -- --- - _- - —
A. V1 1. 02-3 C.O4-6 0.0 i or aore
!. Nave of receiving water or voters _1 ]�_rc� 01(lf- .,
•10. Does your discharge contain or is it possible for your" discharge to eontaia
one or art of the following substances jg= as a result of your operations.
activities, or process#$: arwanIS, cyanides. alwainua,.berylli o, eadmia,
chromium. copper. load, aorcu, Bickel. seieniu•,. tlnc, pianols, eii OWgrease,yanQ lorine (residual .
A. ` 0.0 n0
i certify that 1 as familiar with the info"Utlon contained io tht application and
that to the best of ay knowledge and belief such inforaition is trwo , complete, end
accurate.
a6PA(I.-
Printed Raw of Person Signing
Title
Date Application Signed
�Signatun Of Applicant
!Forth Carolina General Statute 143-215.G(b)(2) providesthat: Atty person who knowinitly makes
Any false, statement representation, or cert cat on any application,'record, report, plan;
or other document files or required to be maintained undar Article 21-or regulations of the
tnvironnental Management Comniastop implemouttag that Article, or mho falsifies, tmpers ulih.
car knowiy renders inaccurate any:=acordin= or nonitoritg #pvtce or loethod required to be
operated or maintained under Ay��Q1e 2.1-. oir• regulatict:s of the Znvtroumeutal Manage Corssis�
implementing that Article, .shall be7'1"ty of is misdemeanor punishable by a •fits- not to exceed
or by imprisonment not to exceed six months, or by both. (18 U.S.C. Section 1001 prow.
a punishment by a fine of'not more than $10,000 or ieprisorawmt not more than S years, or both
for a similar offense.)

ReCEIVE0
M $fATE a
F>Uloci Cz EnVIRQNMOIAL :alArll�
MODRESVILLE State of North Carolina
DepWme`tn of Environment, Health, and Natural Resources
Division of Environmental Management
512 North Salisbury Street • Raleigh, North Carolina 27611
James G. Martin, Governor
William W. Cobey, Jr., Secretary
Mr. Homer P. Edwards
Route 16, Box 38
Statesville, N.C. 28677
George T. Everett, Ph.D.
Director
June 29, 1990
Subject: Permit No. NCO045012 '
Hill Maven Skilled Nursing Home
Iredell County
Dear Mr. Edwards:
q0?
In accordance with your application for discharge permit received on March 6,
1989, we are forwarding herewith the'subject State - NPDES 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 US Environmental Protection
Agency dated December 6, 1983.
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,
Post Office Drawer 11666, Raleigh, North Carolina 27604. Unless such demand is made,
this decision shall be final and binding.
Please take notice that this permit is not transferable. Part II, D.3.
addresses the requirements to be followed in case of change in ownership or control of
this discharge.
This permit does not affect the legal requirements to obtain other permits
which may be required by the Division of Environmental Management or permits required
by the Division of Land Resources, 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 Mr. Jule
Shanklin at telephone number 919/733-5083.
Sincerely,
WOW sianod by,
�f Qvercash f �3or
George T. Everett
Director
cc: Mr. Jim Patrick, EPA
Moor_esv�- i-lle.'R.eg.ionaL Off-i:ce
Poffudon Prevendon Pays
P.O. Box 27687, Raleigh, North Carolina 27611-7687 Telephone [phone]
An Equal Opportunity Affirmative Action Employer

Permit No. NC0045012.
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOURCES
DIVISION OF ENVIRONMENTAL MANAGEMENT
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,
Hill Haven Skilled Nursing Home
is hereby authorized to discharge wastewater from a facility located at.
Hill Haven Nursing Home
Hill_ Haven Road ( NCSR 1381 )
Barium Springs
Iredell County
to receiving waters designated as an unnamed tributary to Third Creek in the Yadkin -Pee Dee River
Basin
in accordance with effluent limitations, monitoring requirements, and other conditions set forth in
Parts I, II, and III hereof.
This permit shall become effective August 1, 1990
This permit and the authorization to discharge shall expire at midnight on July 31, 1994
Signed this day June 29, 1990
Original signed by
Dale Overcash for
George T. Everett, Director
Division of Environmental Management
By Authority of the Environmental Management Commission

i
a �
Permit No. NCO045012
SUPPLEMENT TO PERMIT COVER SHEET
Hill Haven Skilled Nursing Home
is hereby authorized to:
1. Continue to operate an existing 0.018 MGD wastewater treatment facility consisting of two
septic tanks with two surface sand filters and effluent chlorination located at Hill Haven Nursing
Home, Hill Haven Road (NCSR 1381 ), Barium Springs, Iredell County (See Part III of this
Permit), and
2. Discharge from said treatment works at the location specified on the attached map into an
unnamed tributary to Third Creek which is classified Class C waters in the Yadkin -Pee Dee
River Basin.

r
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�-M lAg v &y, 1 U N
(4,,,. f\l ,�
Lob �So 2 TROUTMAN QUADRANGLE v�
1 I NORTH CAROLINA ay��PSc
✓�a�-� l ��+''� 7.5 MINUTE SERIES (TOPOGRAPHIC) `5cP
55' 508 509. STATES VILLE 2.5 A! � 5101 11440000 FEET 5111 80°52'30"
—900
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730000
\�W�iTedell `, ,/� / FEET
n'\ 3955
-- ,� �\`J1 `-' ,�' / 1 0 � -��•• it S _�� to
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ig_h5c
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A. (). EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS SUMMER (April 1- October 31) Permit No. NCO045012
During the period beginning on the effective date of the permit and lasting until expiration, the Permittee is authorized to discharge from
outfall(s) serial number 001. Such discharges shall be limited and monitored by the permittee as specified below:
Effluent Characteristics
Discharge Limitations
Monitoring
Requirements
Measurement
Sample
*Sample
Monthly AvgL Weekly Avg.
Daily Max
Frequency
Type
Location
Flow
0.018 MGD
Weekly
Instantaneous
I or E
BOD, 5 day, 200C
30.0 mg/I
45.0 mg/I
2/Month
Grab
E
Total Suspended Residue
30.0 mg/I
45.0 mg/I
2/Month
Grab
E
NH3 as N
9.4 mg/I
2/Month
Grab
E
Fecal Coliform (geometric mean)
200.0 /100 ml
400.0 /100 ml
2/Month
Grab
E
Total Residual Chlorine
Daily
Grab
E
Temperature
Weekly
Grab
E
y` Sample locations: E - Effluent, I - Influent
'The pH shall not be less than 6.0 standard units nor greater than 9.0 standard units and shall be monitored 2/month at the effluent by grab
sample.
There shall be no discharge of floating solids or visible foam in other than trace amounts.

A. (). EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS WINTER (November 1 - March 31) Permit No. NCO045012
During the period beginning on the effective date of the permit and lasting until expiration, the Permittee is authorized to discharge from
outfall(s) serial number 001. Such discharges shall be limited and monitored by the permittee as specified below:
Effluent Characteristics
Flow
BOD, 5 day, 200C
Total Suspended Residue
NH3 as N
Fecal Coliform (geometric mean)
Total Residual Chlorine
Temperature
Discharge Limitations
Monthly Avg, Weekly Avg_ Daily Max
0.018 MGD
30.0 mg/I 45.0 mg/I
30.0 mg/I 45.0 mg/I
30.0 mg/I
200.0 /100 ml 400.0 /100 ml
Monitoring
Requirements
Measurement
Sample
*Sample
Frequency
Tue
Location
Weekly
Instantaneous
I or E
2/Month
Grab
E
2/Month
Grab
E
2/Month
Grab
E
2/Month
Grab
E
Daily
Grab
E
Weekly
Grab
E
Sample locations: E - Effluent, I - Influent
The pH shall not be less than 6.0 standard units nor greater than 9.0 standard units and shall be monitored 2/month at the effluent by grab
sample.
There shall be no discharge of floating solids or visible foam in other than trace amounts.

PART I
Section B. Schedule of Compliance
1. The permittee shall comply with Final Effluent Limitations specified for discharges in
accordance with the following schedule:
Permittee shall comply with Final Effluent Limitations by the effective date of the
permit unless specified below.
2. Permittee shall at all times provide the operation and maintenance necessary to operate the
existing facilities at optimum efficiency.
3. No later than Wcalendar days following a date identified in the above schedule of
compliance, the permittee shall submit either a report of progress or, in the case of specific
actions being required by identified dates, a written notice of compliance or noncompliance.
In the latter case, the notice shall include the cause of noncompliance, any remedial actions
taken, and the probability of meeting the next schedule requirements.

Part II
Page 1 of 14
PART II
STANDARD CONDITIONS FOR NPDES PERMITS
SECTION A. DEFINITIONS
1. Permit Issuing Authority
The Director of the Division of Environmental Management.
2. DEM or Division
Means the Division of Environmental Management, Department of Environment, Health
and Natural Resources.
3. EM
Used herein means the North Carolina Environmental Management Commission.
4. Act or "the Act"
The Federal Water Pollution Control Act, also known as the Clean Water Act, as amended,
33 USC 1251, et. seq.
5. Mass/Day Measurements
a. The "monthly average discharge" is defined as the total mass of all daily discharges
sampled and/or measured during a calendar month on which daily discharges are
sampled and measured, divided by the number of daily discharges sampled and/or
measured during such month. It is therefore, an arithmetic mean found by adding the
weights of the pollutant found each day of the month and then dividing this sum by the
number of days the tests were reported. The limitation is identified as "Monthly
Average" in Part I of the permit.
b. The "weekly average discharge" is defined as the total mass of all daily discharges
sampled and/or measured during the calendar week (Sunday -Saturday) on which daily
discharges are sampled and measured, divided by the number of daily discharges
sampled and/or measured during such week. It is, therefore, an arithmetic mean found
by adding the weights of pollutants found each day of the week and then dividing this
sum by the number of days the tests were reported. This limitation is identified as
"Weekly Average" in Part I of the permit.
c. The "maximum daily discharge" is the total mass (weight) of a pollutant discharged
during a calendar day. If only one sample is taken during any calendar day the weight
of pollutant .calculated from it is the "maximum daily discharge." This limitation is
identified as "Daily Maximum," in Part I of the permit.

Part II
Page 2 of 14
d. The "average annual discharge" is defined as the total mass of all daily discharges
sampled and/or measured during the calendar year on which daily discharges are
sampled and measured, divided by the number of daily discharges sampled and/or
measured during such year. It is, therefore, an arithmetic mean found by adding the
weights of pollutants found each day of the year and then dividing this sum by the
number of days the tests were reported. This limitation is defined as "Annual Average"
in Part I of the permit.
6. Concentration Measurement
a. The "average monthly concentration," other than for fecal coliform bacteria, is the sum
of the concentrations of all daily discharges sampled and/or measured during a calendar
month on which daily discharges are sampled and measured, divided by the number of
daily discharges sampled and/or measured during such month (arithmetici mean of the
daily concentration values). The daily concentration value is equal to the concentration
of a composite sample or in the case of grab samples is thearithmetic mean (weighted
by flow value) of all the samples collected during that calendar day. .The average
monthly count for fecal coliform bacteria is the geometric mean of the counts for
samples collected during a calendar month. This limitation is identified as "Monthly
Average" under "Other Limits" in Part I of the permit.
b. The "average weekly concentration," other than for. fecal coliform bacteria, is the sum
of the concentrations of all daily discharges sampled and/or measured during a calendar
week (Sunday/Saturday) on which daily discharges are sampled and measured divided
by the number of daily discharges sampled and/or measured during such week
(arithmetic mean of the daily concentration values). The daily concentration value is
equal to the concentration of a composite sample or in the case of grab samples is the
arithmetic mean (weighted by flow value) of all the samples collected during that
calendar day. The average weekly count for fecal coliform bacteria is the geometric
mean of the counts for samples collected during a calendar week. This limitation is
identified as "Weekly Average" under "Other Limits" in Part I of the permit.
c. The "maximum daily concentration" is the concentration of a pollutant discharge during
a calendar day. If only one sample is taken during any calendar day the concentration
of pollutant calculated from it is the "Maximum Daily Concentration". It is identified
as 'Daily Maximum" under "Other Limits" in Part I of the permit.
d. The "average annual concentration," other than for fecal coliform bacteria, is the sum of
the concentrations of all daily discharges sampled and/or measured during a calendar
year on which daily discharges are sampled and measured divided by the number of
daily discharges sampled and/or measured during such year (arithmetic mean of the
daily concentration values). The daily concentration value is equal to the concentration
of a composite sample or in the case of grab samples is the arithmetic mean (weighted
by flow value) of all the samples collected during that calendar day . The average
yearly count for fecal coliform bacteria is the geometric mean of the counts for samples
collected during a calendar year. This limitation is identified as "Annual Average"
under "Other Limits" in Part I of the permit.
e. The "daily average concentration" (for dissolved oxygen) is the minimum allowable
amount of dissolved oxygen required to be available in the effluent prior to discharge
averaged over a calendar day. If only one dissolved oxygen sample is taken over a
calendar day, the sample is considered to be the "daily average concentration" for the
discharge. It is identified as "daily average" in the text of Part I.

Part II
Page 3 of 14
f. The "quarterly average concentration" is the average of all samples taken over a
calendar quarter. It is identified as "Quarterly Average Limitation" in the text of Part I
of the permit.
g. A calendar quarter is defined as one of the following distinct periods: January through
March, April through June, July through September, and October through December.
7. Other Measurements
a. Flow, (MGD): The flow limit expressed in this permit is the 24 hours average flow,
averaged monthly. It is determined as the arithmetic mean of the total daily flows
recorded during the calendar month.
b. An "instantaneous flow measurement" is a measure of flow taken at the time of
sampling, when both the sample and flow will be representative of the total discharge.
c. A "continuous flow measurement" is a measure of discharge flow from the facility
which occurs continually without interruption throughout the operating hours of the
facility. Flow shall be monitored continually except for the infrequent times when
there maybe no flow or for infrequent maintenance activities on the flow device.
8. Types o� les
a. Composite Sample: A composite sample shall consist of.
(1) a series.of grab samples collected at equal time intervals over a 24 hour period of
discharge and combined proportional to the rate of flow measured at the time of
individual sample collection, or
(2) a series of grab samples of equal volume collected over.a 24 hour period with the
time intervals between samples. determined by a preset number of gallons passing
the sampling point. Flow measurement between sample intervals shall be
determined by use of a flow recorder and totalizer, and the present gallon interval
between 'sample collection fixed at no greater than 1/24 of the expected total daily
flow at the treatment system, or
(3) a single,- continuous sample collected over a 24 hour period proportional
to the rate of flow.
In accordance with (1) above, the time interval between influent grab samples shall be
no greater than once per hour, and the time interval between effluent grab samples shall
be no greater than once per hour except at wastewater treatment _ systems having a
detention time of greater than 24 hours. In such cases, effluent grab samples may be
collected at time intervals evenly spaced over the 24 hour period which are equal in
number of hours to the detention time of the system in number of days. However, in
no case may the time:interval between effluent grab samples be greater than six (6)
hours nor the number of samples less than four (4) during a 24 hour sampling period.
b. Grab Sample: Grab samples are individual samples collected over a period of time not
exceeding 15 minutes; the grab sample can be taken manually.
9. Calculation of Means
a Arithmetic Mean: The arithmetic mean of any set of values is the summation of the
individual values. divided by the number of individual values.

Part H
Page 4 of 14
b. Geometric Mean: The geometric mean of any set of values. is the Nth root of the
product of the individual values where N is equal to the number of individual values.
The geometric mean is equivalent to the antilog of the arithmetic mean of the logarithms
Of the individual values. For purposes of calculating the geometric mean, values of
zero (0) shall be considered to be one (1).
c. Weighted by Flow Value: Weighted by flow value means the summation of each
concentration times its respective flow divided by the summation of the respective
flows. .
10. Calendar Day
A calendar day is defined as the period from midnight of one day until midnight of the next
day. However, for purposes of this permit, any, consecutive 24-hour period that
reasonably represents the calendar day may be used for sampling.
11. Hazardous Substance
A hazardous substance means any substance designated under 40 CFR Part 116 pursuant
to Section 311 of the Clean Water Act.
12. Toxic Pollutant
A. toxic pollutant is any pollutant listed as toxic under Section 307(a)(1) of the Clean Water
Act.
SECTION B. GENERAL CONDITIONS
The permittee must comply with all conditions of this permit. Any permit noncompliance
constitutes a violation of the Clean Water Act and is ground for enforcement action; for
permit termination, revocation and reissuance, or modification; or denial of -a permit
renewal application.
a. The permittee shall comply with effluent standards or prohibitions established under
section 307(a) of the Clean Water Act for toxic pollutants within the time'provided in
the regulations that. establish these standards or prohibitions, even if the permit has not
yet been modified to incorporate the requirement..
b. Any person who violates a permit condition is subject to a civil penalty not to exceed
$25,000 per day for each violation. Any person who negligently violates any permit
condition is subject to criminal penalties of $2,500 to $25,000 per day of violation, or
imprisonment for not more than 1 year, or both: Any person who knowingly violates
permit conditions is subject to criminal penalties of $5,000 to $50,000 per day of
violation, or imprisonment for not more than 3. years, or both.. Also, any person who
violates a 'permit condition may be assessed an administrative penalty not to exceed
$10,000 per violation with the maximum amount not to exceed $125,000. [Ref: 40
j CFR 122.41(a)]

Part II
Page 5 of 14
2. Duty to Mitigate
The permittee shall take all reasonable steps to minimize or prevent any discharge in
violation of this permit which has a reasonable likelihood of adversely affecting human
health or the environment.
3. Civil and Criminal Liability
Except as provided in permit conditions on "Bypassing" (Part II, B-3) and 'Power
Failures" (Part II, B-6), nothing in this permit shall be construed to relieve the permittee
from any responsibilities, liabilities, or penalties for noncompliance pursuant to NCGS
143-215.3, 143-215.6 or Section 309 of the Federal Act, 33 USC 1319. Furthermore, the
permittee is responsible for consequential damages, such as fish kills, even though the
responsibility for effective compliance may be temporarily suspended.
4. Oil and Hazardous Substance Liabili
Nothing in this permit shall be construed to preclude the institution of any legal action or
relieve the permittee from any responsibilities, liabilities, or penalties to which the permittee
is or may be subject to under NCGS 143-215.75 et seq. or Section 311 of the Federal Act,
33 USG 1321. Furthermore, the permittee is responsible for consequential damages, such
as fish kills, even though the responsibility for effective compliance may be temporarily
suspended.
5. Property Rights
The issuance of this permit does not convey any property rights in either real or personal
property, or any exclusive°privileges, nor does it authorize any injury to private property or
any invasion of personal rights, nor any infringement of Federal, State or local laws or
regulations.
6. Onshore or Offshore Construction
This permit does not authorize or approve the construction of any onshore or offshore
physical structures or facilities or the undertaking of any work in any navigable waters.
7. Severability
The provisions of this permit are severable, and if any provision of this permit, or the
application of any provision of this permit to any circumstances, is held invalid, the
application of such provision to other circumstances, and the remainder of this permit, shall
not be affected thereby.
8. Duty to Provide Information
The permittee shall furnish to the Permit Issuing Authority, within a reasonable time, any
information which the Permit Issuing Authority may request to determine whether cause
exists for modifying, revoking and reissuing, or terminating this permit or to determine
compliance with this permit. The permittee shall also furnish to the Permit Issuing
Authority upon request, copies of records required to be kept by this permit.
9. Duly to ReVnply
If the permittee wishes to continue an activity regulated by this permit after the expiration
date of this permit, the permittee must apply for and obtain a new.permit.

Part II
Page 6 of 14
10. Expiration of Permit
The permittee is not authorized to discharge after the expiration date. In order to receive
automatic authorization to discharge beyond the expiration date, the permittee shall submit
such information, forms, and fees as are required by the agency authorized to issue permits
no later than 180 days prior to the expiration date. Any discharge that has not requested
renewal at least 180 days prior to expiration, or any discharge that does not have a permit
_after the expiration and has not requested renewal at least 180 days prior to expiration, will
subject the permittee to enforcement procedures as provided in NCGS 143-215.6 and 33
USC 1251 et. seq.
11. Signatory Requirements
All applications, reports, or information submitted to the Permit Issuing Authority shall be
signed and certified.
a. All permit applications shall be signed as follows:
(1) For a corporation: by a responsible corporate officer. For the purpose of this
Section, a responsible corporate officer means: (a) a president, secretary, treasurer
or vice president of the corporation in charge of a principal business function, or
any other person who performs similar policy or decision making functions for the
corporation, or (b) the manager of one or more manufacturing production or
operating facilities employing more than 250 persons or having gross annual sales
or expenditures exceeding 25 million (in second quarter 1980 dollars), if authority to
sign documents has been assigned or delegated to the manager in accordance with
corporate procedures.
(2) For a partnership or sole proprietorship: by a general partner or the proprietor,
respectively; or
(3) For a municipality, State, Federal, or other public agency: by either a principal
executive officer or ranking elected official.
b. All reports required by the permit and other information requested by the Permit Issuing
Authority shall be signed by a person described above or by a duly authorized
representative of that person. A person is a duly authorized representative only if:
(1) The authorization is made in writing by a person described above;
(2) The authorization specified either an individual or a position having responsibility
for the overall operation of the regulated facility or activity, such as the position of
plant manager, operator of a well or well field, superintendent, a position of
equivalent responsibility, or an individual or position having overall responsibility
for environmental matters for the company. (A duly authorized representative may
thus be either a named individual or any individual occupying a named position.);
and
(3) The written authorization is submitted to the Permit Issuing Authority.

Part H
Page 7 of 14
c. Certification. Any person signing a document under paragraphs a. or b. of this section
shall make the following certification:
"I certify, under penalty of law, that this document and all -attachments were prepared
.under my direction or supervision in accordance with a system designed to assure that
qualified personnel properly gather and evaluate the information submitted. Based on
my inquiry of the person or persons who manage the system, or those persons directly
responsible for gathering the information, the information submitted is, to the best of
my knowledge and believe, true, accurate, and complete. I am aware that .there are
significant penalties for submitting false information, including the possibility of fines
and imprisonment for knowing violations.
12. Permit -Actions
This permit may be modified, revoked and reissued, or terminated for cause.The filing of a
request by the permittee for a permit modification, revocation and reissuance; or
termination, or a notification of planned changes or anticipated noncompliance does not
stay any permit condition.
13. Permit Modification. Revocation and Rei nuance. or Termination
The issuance of this permit does not prohibit the permit issuing authority from reopening
and modifying the permit, revoking and reissuing the permit, or terminating the permit as
allowed by the laws, rules, and regulations contained in Title 40, Code of Federal
Regulations, Parts 122 and.123; Title 15 of the North Carolina Administrative Code,
Subchapter 2H .0100; and North Carolina General Statute 143-215.1 et. al.
14. _ Previous Permits
All previous National Pollutant Discharge Elimination System Permits issued to this
facility, whether for operation or discharge, are hereby revoked by issuance of this permit.
The conditions, requirements, terms, and provisions of this permit authorizing discharge
under the National Pollutant Discharge Elimination System govern discharges from this-
facility. -
SECTION C. OPERATION AND MAINTENANCE OF POLLUTION CONTROL
1. Certified Operator
Pursuant to Chapter 90A-44 of North Carolina General Statutes, the permittee shall
employ a certified wastewater treatment plant operator in responsible charge (ORC) of the
wastewater treatment. facilities. Such operator must hold a certification of the grade
equivalent to or greater than the classification- assigned to the wastewater treatment
facilities. The permittee shall notify the Division's Operator Training and Certification Unit
within five days of any change in the ORC status..

Part H'
Page 8 of 14
2. Proper Qperation and Maintenance
The.permittee shall at all times. properly operate and maintain all facilities and systems of
treatment and control (and related appurtenances) which -are installed or used by the
permittee to achieve compliance with the conditions of this permit. Proper operation and
maintenance also includes adequate laboratory controls and appropriate quality assurance
procedures. This. provision requires the operation of back-up or auxiliary facilities or
similar systems which are installed by a permittee only when the operation is necessary to
achieve compliance with the conditions of the permit.
3. _Need to Halt or Reduce not a Defense
It shall not be a defense for a permittee in an enforcement action that it would have been
necessary to halt or reduce the permitted activity in order to maintain compliance with the
condition of this permit.
4. Bypassing of Treatment Facilities
a. Definitions
(1) 'Bypass" means the known diversion of waste streams -from any portion of a
treatment facility including the collection system, which is not a designed or
established or operating mode for the facility.
(2) "Severe property damage" means substantial physical damage to property, damage
to the treatment facilities which causes them to become inoperable, or substantial
and permanent loss of natural resources. which can reasonably -be expected to occur
in the absence of a bypass. -Severe property damage does not mean economic loss
caused by delays in. production.
b. Bypass not exceeding limitations.
The permittee may allow any bypass to occur which does not cause effluent limitations
to be exceeded, but only if it also. is for essential maintenance to assure efficient
operation. 'These bypasses are not subject to the provisions of Paragraphs c.: and d. of
this section.
c. Notice
(1) Anticipated bypass. If the permittee knows in advance of the need for a bypass, it
shall submit prior notice, if possible at least ten days before the date of the bypass;
including an evaluation of the anticipated quality -and affect of the bypass.
(2) Unanticipated bypass. The permittee shall submit notice of anunanticipated bypass
as required in Part.II, E. 6. of this permit. (247hour notice).
d. Prohibition of Bypass
(1) Bypass is prohibited and the Permit Issuing Authority may take enforcement action
against a permittee for bypass, unless:
(a) Bypass was unavoidable to prevent loss of life, personal injury or .severe
property damage;

Part II
Page 9 of 14
(b) There were no feasible alternatives to the. bypass, such as the use of auxiliary
treatment facilities, retention of untreated wastes or maintenance during normal
periods of equipment downtime. This condition is not satisfied if adequate
backup equipment should have been installed in the exercise of reasonable
engineering judgment to prevent a bypass which occurred during normal
periods of equipment downtime or preventive maintenance; and
(c) The permittee submitted notices as required under Paragraph c. of this section.
(2) The Permit Issuing Authority may approve an anticipated bypass, after considering
its adverse affects, if the Permit Issuing Authority determines that it will meet the
three conditions listed above in Paragraph d. (1) of this section.
5. Upsets
a. Definition.
"Upset " means an exceptional incident in which there is unintentional and
temporary noncompliance -with technology based permit effluent limitations because of
factors beyond the reasonable control of the permittee. An upset does not include
noncompliance to the extent caused by operational error, improperly designed treatment
facilities; inadequate treatment facilities, lack of preventive maintenance, or careless or
improper operation.
b. Affect of an upset.
An upset constitutes an affirmative defense to an action brought for
noncompliance with such technology based permit effluent limitations if the
requirements of paragraph (3) of this condition met.. No determination made during
administrative review of claims that noncompliance was caused by upset, and before. an
action for noncompliance, is final administrative action subject to judicial review.
c. Conditions necessary for a demonstration of upset.
A permittee who wishes to establish the affirmative defense of upset shall demonstrate,
through properly signed, contemporaneous operating logs, or other relevant evidence
that:
(a) An upset occurred and that the permittee can identify the cause(s) of the upset;
(b) The permittee facility was at the time being properly operated; and
(c) The permittee submitted notice of the upset- as required in Part II, E. 6. (b) (B) of
this permit.
(d) The permittee complied with any remedial measures required under Part II, B. 2. of
this permit.
d. Burden of proof.
In any enforcement proceeding the permittee seeking to establish the occurrence of an
upset has the burden of proof.

Part II
Page 10 of 14
6. Removed Substances
Solids, sludges, filter backwash, or other pollutants removed in the course of treatment or
control of wastewaters shall be disposed of in accordance with NCGS 143-215.1 and in a
manner such as to prevent any pollutant from such materials from entering waters of the
State or navigable waters of the United States. The permittee shall comply with all existing
federal regulations governing the disposal of sewage sludge, and with applicable 40 CFR
Part 503 Standards for the Use and Disposal of Sewage Sludge when promulgated. Upon
promulgation of 40 CFR Part 503, any permit issued by the Permit Issuing Authority for
the disposal of sludge may be reopened and modified, or revoked and reissued, to
incorporate applicable requirements at 40 CFR Part 503. The permittee shall notify the
Permit Issuing Authority of any significant change in its sludge use or disposal practices.
7. Power Failures
The permittee is responsible for maintaining adequate safeguards as required by DEM
Regulation, Title 15, North Carolina Administrative Code, Subchapter 2H, .0124
Reliability, to prevent the discharge of untreated or inadequately treated wastes during
electrical power failures either by means of alternate power sources, standby generators or
retention of inadequately treated effluent.
SECTION D. MONITQRING AND RECORDS
1. Representative Sampling
Samples collected and measurements taken, as required herein, shall be characteristic of the
volume and nature of the permitted discharge. Samples collected at a frequency less than
daily shall be taken on a day and time that is characteristic of the discharge over the entire
period which the sample represents. All samples shall be taken at the monitoring points
specified in this permit and, unless otherwise specified, before the effluent joins or is
diluted by any other wastestream, body of water, or substance. Monitoring, points shall
not be changed without notification to and the approval of the Permit Issuing Authority.
Monitoring results obtained during the previous month(s) shall be summarized for each
month and reported on a monthly Discharge Monitoring Report (DMR) Form (DEM No.
MR 1, 1.1, 2, 3) or alternative forms approved by the Director, DEM, postmarked no later
than the 30th day following the completed reporting period.
The first DMR is due on the last day of the month_ following the issuance of the permit or in
the case of a new facility, on the last day of the month following the commencement of
discharge. Duplicate signed copies of these, and all other reports required herein, shall be
submitted to the following address:
Division of Environmental Management
Water Quality Section
ATTENTION: Central Files
Post Office Box 27687
Raleigh, North Carolina 27611

Part II
Page 11 of 14
3. Flow Measurements
Appropriate flow measurement devices and methods consistent with accepted scientific
practices shall be selected and used to ensure the accuracy and reliability of measurements
of the -volume of monitored discharges. The devices shall be installed, calibrated and
maintained to ensure that the accuracy of the measurements are consistent with the accepted
capability of that type of device. Devices selected shall be capable of measuring flows'with
a maximum deviation of less than + 10% from the true discharge rates throughout the range
of -expected discharge volumes. Once -through condenser -cooling water flow which is
monitored by pump logs, or pump hour meters as specified in Part I of this permit and
based on themanufacturer's pump curves shall not be subject to this requirement.
Test procedures for the analysis of pollutants shall conform to the EMC regulations
published pursuant to NCGS 143-215.63 et. seq, the Water and Air Quality Reporting Acts,
and to regulations published pursuant to Section 304(g),. 33. USC -1314, of the Federal
Water Pollution Control Act, as Amended; and Regulation 40 CFR 136.
To meet the intent of the monitoring required by this permit, all test procedures must
produce minimum detection and reporting levels that are below the permit discharge
requirements and all data generated must be reported.down to the minimum detection or
lower reporting level of the procedure. If no approved methods are determined capable of
achieving minimum detection and reporting. levels below permit discharge requirements,
then the most sensitive (method with the lowest possible detection and reporting level)
approved method must be used.
5. Penalties for Tampgring
The Clean Water Act provides that any person who falsifies, tampers with, or knowingly
renders inaccurate, any monitoring device or method required to be maintained under this
permit shall, upon conviction, be punished .by a fine of not more than $10,000 per
violation, or by imprisonment for not more than two years per violation, or by both.
6. Records Retention
The permittee shall retain records of all monitoring information, including all calibration
and maintenance records and all original strip chart recordings for continuous monitoring
instrumentation, copies of all reports required -by this permit, for a period ' of at least 3
years from the date of the sample, measurement, report or application. This period may be
extended by request of the Director at any time.
7. Recording Results
For each measurement or sample taken pursuant to the requirements of this permit, the
permittee shall record the following information:
a. The date, exact place, and time of sampling or measurements;
b. The individ'ual(s). who performed the sampling or measurements;
c. The date(s) analyses were performed;
d. The individual(s) who performed the analyses;
e. The analytical techniques or methods used; and
f.: The results of such analyses. . .

Part II
Page 12 of 14
8. Inspection and Entry
The permittee shall allow the Director, or an authorized representative, upon the
presentation of credentials and other documents as may be required by law, to;
a. Enter upon the permittee's premises where a regulated facility or activity is located or
conducted, or where records must be kept under the conditions of this permit;
b. Have access to and copy, at reasonable times, any records that must be kept under the
conditions of this permit;
c. Inspect at reasonable times any facilities, equipment (including monitoring and control
equipment), practices, or operations regulated or required under this permit; and
d. Sample or monitor at reasonable times, for the purposes of assuring permit compliance
or as otherwise authorized by the Clean Water Act, any substances or parameters at any
location.
SECTION E. REPORTING REQUIREMENTS
1. Change in Discharge
All discharges authorized herein- shall be consistent with the terms and conditions of this.
permit. The discharge of any pollutant identified in this permit more frequently than or at a
level in excess of that authorized shall constitute a violation of the permit.
2. - Planned Chances
The permittee shall give notice to the Director as soon as possible of any planned physical
alterations or additions to the perrnutted facility. Notice is required only when:
The alteration or addition to a permitted facility may meet one of the criteria for
determining whether a facility is a new source in 40 CFR Part 122.29 (b); or,
b. The alteration or addition could significantly change the nature or increase the quantity
of pollutants discharged. This notification applies to pollutants which are subject
neither to effluent limitations in the permit, nor to, notification requirements under 40
CFR Part 122.42 (a) (1).
3. Anticipated Noncompliance
The permittee shall give advance notice to the Director of any planned changes in the
permitted facility or activity which may result in noncompliance with permit requirements.
4. Transfers
This permit is not transferable to any person except after notice to the Director. The
Director may require modification or revocation and reissuance of the permittee and
incorporate such other requirements as may be necessary under the Clean Water Act.

Part lI
Page 13 of 14
5. Monitoring_ Reports
Monitoring results shall be reported at the intervals specified elsewhere in this permit.
a. Monitoring results must be reported on a Discharge Monitoring Report (DMR) (See
Part II. D. 2. of this permit).
b. If the permittee monitors any pollutant more frequently than required by the permit,
using test .procedures specified in Part II, D. 4. of this permit, the results of this
monitoring shall be included in the calculation and reporting of the data submitted in the
DMR.
c. Calculations for all limitations which require averaging of measurements shall utilize an
arithmetic mean unless otherwise specified by the Director in the permit.
6. Twenty-four Hour Reporting,
a. The permittee shall report to the central office or the appropriate regional office any
noncompliance which may endanger health or the environment. Any information shall
be provided orally within 24 hours from the time the permittee became aware of the
circumstances. A written submission shall also be provided within 5 days of the time
the permittee becomes aware of the circumstances. The written submission shall
contain a description of the noncompliance, and its cause; the period of noncompliance,
including exact dates and times, and if the noncompliance has not been corrected, the
anticipated time it is expected to continue; and steps taken or planned to reduce,
eliminate, and prevent reoccurrence of the noncompliance.
b. The following shall be included as information which must be reported within 24 hours
under this paragraph.
(A) Any unanticipated bypass which exceeds any effluent limitation in the permit.
(B) Any upset which exceeds any effluent limitation in the permit.
(C) Violation of a maximum daily discharge limitation for any of the pollutants listed by
the Director in the permit to be reported within 24 hours.
c. The Director may waive the written report on a case -by -case basis for reports under
paragraph b: above of this condition if the oral report has been received within 24
hours.
7. Other Noncompliance
The permittee shall report all instances of noncompliance not reported under Part II. E. 5
and 6. of this permit at the time monitoring reports are submitted. The zports shall contain
the information listed in Part H. E. 6. of this permit.
8. Other Information
Where the permittee becomes aware that it failed to submit any relevant facts in a permit
application, or submitted incorrect information in a permit application or in any report to the
Director, it shall promptly submit such facts or information.

w
Part I1
Page 14 of 14
9. Noncompliance Notification
The permittee shall report by telephone to either the central office or the appropriate regional
office of the Division as soon as possible, but in no case more than 24 hours or on the next
working day following the occurrence or first knowledge of the occurrence of any of the
following:
a. Any occurrence at the water pollution control facility which results in the discharge of
significant amounts of wastes which are abnormal in quantity or characteristic, such as
the dumping of the contents of a sludge digester; the known passage of a slug of
hazardous substance through the facility; or any other unusual circumstances..
b. Any process unit failure, due to known or unknown reasons, that render the facility
incapable of adequate wastewater treatment such as mechanical or electrical failures of
pumps, aerators, compressors, etc.
C. Any failure of a pumping station, sewer line, or treatment. facility resulting in a by-pass
directly to receiving waters without treatment of all or any portion of the influent to
such station or facility.
Persons reporting such occurrences by telephone shall also, file a written report in letter
form within 15 days following first knowledge of the occurrence.
10. Availability of Reports
Except for data determined to be confidential under NCGS 143-215.3(a)(2) or. Section 308
of the Federal Act, 33 USC 1318, all reports prepared in accordance with the terms shall be
available for public inspection at the offices of the Division of Environmental Management.
As required by the -Act, effluent data shall not be considered confidential. Knowingly
making any false statement on any such, report may, result in the imposition of criminal
penalties as provided for in NCGS 143-215.1(b)(2) or in Section 309 of the Federal Act.
11. Penalties for Falsification of R
The Clean Water Act provides that any person who knowingly makes any false'statement,
representation, or certification in any record or other document submitted or required to be
maintained under this permit, including monitoring reports or reports ,of compliance or
noncompliance shall, upon conviction, be punished by a ,fine of not more than $10000 per
i
violation, or by imprisonment for not more than two years per violation, or by both._

PART III
OTHER REQUIREMENTS
A. Construction
No construction of wastewater treatment facilities or additions to add to the plant's treatment
capacity or to change the type of process utilized at the treatment plant shall be begun until Final
Plans and Specifications have been submitted to the Division of Environmental Management
and written approval and Authorization to Construct has been issued.
B . Groundwater Monitoring
The permittee shall, upon written notice from the Director of the Division of Environmental
Management, conduct groundwater monitoring as may be required to determine the compliance
of this NPDES permitted facility with the current groundwater standards.
C. Changes in Discharges of Toxic Substances
The permittee shall notify the Permit Issuing Authority as soon as it knows or has reason to
believe:
a. That any activity has occurred or will occur which would result in the discharge, on a
routine or frequent basis, of any toxic pollutant which is not limited in the permit, if that
discharge will exceed the highest of the following "notification levels';
(1) One hundred micrograms per liter (100 ug/1);
(2) Two hundred micrograms per liter (200 ug/1) for acrolein and acrylonitrile; five hundred
micrograms per liter (500 ug/1) for 2.4-dinitrophenol and for
2-methyl-4.6-dinitrophenol; and one milligram per liter (1 mg/1) for antimony;
(3) Five (5) times the maximum concentration value reported for that pollutant in the permit
application.
b. That any activity has occurred or will occur which would result in any discharge, on a
non -routine or infrequent basis, of a toxic pollutant which is not limited in the permit, if
that discharge will exceed the highest of the following "notification levels";
(1) Five hundred micrograms per liter (500 ug/1);
(2) One milligram per liter (1 mg/1) for antimony;
(3) Ten (10) times the maximum concentration value reported for that pollutant in the permit
application.

PART IV
ANNUAL ADMINISTERING AND COMPLIANCE FEE REQUIREMENTS
A. The permittee must pay the annual administering and compliance fee within 30
(thirty) days after being billed by the Division. Failure to pay the fee in a
timely manner in accordance with 15 NCAC 2H .0105(b)(4) may cause this Division
to initiate action to revoke the permit.

Date: March 28, 1990
NPDES STAFF REPORT AND RECOMMENDATIONS
County: Iredell
NPDES Permit No.: NC 0045012
PART I - GENERAL INFORMATION
1. Facility and Address: Hill Haven Nursing Home
Route 16, Box 38
Statesville, NC 28677
2. Date of Investigation: March 231 1990
3. Report Prepared By: Allen Hardy, Environmental Engineer I
4. Person Contacted and Telephone Number: Homer Edwards;
704/872-7601 (7602)
51. Directions to Site: From Mooresville, travel Highway 21
North to Hill Haven Road (S. R. 1381). Turn left and the
facilities are on the right.
6. Discharge Point - Latitude: 350 44' 46"
Longitude: 800 35' 44"
Attach a USGS Map Extract and indicate treatment plant site
and discharge point on map.
USGS Quad No.: E 15 NW
7. Size P ( land available for'ex ansion and upgrading): The land
available for expansion and upgrading appeared to be
limited.
8. Topography (relationship to flood plain included): The
topography was rolling with slopes of 2-15%. The facilities
were located in a low lying area adjacent to the creek,
however, they did not appear to be in the flood plain.
9. Location of Nearest Dwelling: The nearest dwelling was
approximately 200 feet from the treatment facilities.
10. Receiving Stream or Affected Surface Waters: Unnamed
tributary to Third Creek
a. Classification: Class I
b. River Basin and Subbasin No.: Yadkin, 03-07-06
C. Describe receiving stream features and pertinent
downstream uses: The receiving stream was
approximately 8-10 feet wide and contained a good flow
on the date of inspection. There are numerous
dischargers located along Third Creek.

Page
Two
PART
II - DESCRIPTION OF DISCHARGE AND TREATMENT WORKS
1.
Type of Wastewater: 100o Domestic
i
0% Industrial
a. Volume of Wastewater: .008 MGD (present average); .018
MGD (design)
b. Types and quantities of industrial wastewater: N/A
C. Prevalent toxic constituents in wastewater: N/A
d. Pretreatment Program (POTWs only): N/A
i2.
Production Rates (industrial discharges only) in Pounds:
N/A
3.
Description of Industrial Process (for industries only) and
Applicable CFR Part and Subpart: N/A
4.
Type of Treatment (specify whether proposed or existing):
The existing treatment consists of two septic tanks with a
combined capacity of 18,000 gallons, two surface sand
filters (one for each tank) and effluent chlorination.
5.
Sludge Handling and Disposal Scheme: Sludge is removed as
i
needed by a septage hauler.
6.
Treatment Plant Classification: Class I
7.
SIC Code(s): 8051
Wastewater Code(s): 11
PART
III - OTHER PERTINENT INFORMATION
1.
Is this facility being constructed with Construction Grants
Funds (municipals only)? N/A
2.
Special monitoring requests: No
3.
Additional effluent limits requests: No
4. Other: No
PART IV - EVALUATION AND RECOMMENDATIONS
The applicant, Hill Haven Nursing Home, plans to continue
discharging domestic wastewater treated in a septic tank -surface
sand filter system. At present the facilities appeared to be
functioning satisfactorily producing a good quality effluent:
However, there did appear to be a need for increased maintenance,
which is being addressed in a Compliance Evaluation Inspection
(CEI).

Page Three
There did not appear to be any problems associated with the
discharge on the receiving stream. It is recommended that the
Permit be reissued.
Signature of'Report Prepar
Water Quality
onal Supervisor

TROUTMAN QUADRANGLE
j NORTH CAROLINA
7.5 MTNIITF '�F.RTFR rmpnnpApu4Tm
145'
rye
91
E 15 tqW

" d.w STA7F o
-RECEIVE
afflSION OF ENVIRONMENTAL JpO / U
O
- MAR 14 1990
MOCRESVILL6
n'°mState of North Carolina
Department of. Environment, Health, and Natural Resources
Division of Environmental Management
512 North Salisbury Street • Raleigh, North Carolina 27611
James G. Martin, Governor 3/13/90
William W. Cobey, Jr., Secretary
Homer P. Edwards, Maintenance
Hill Haven Skilled Nursing Home
Route 16, Box 38
Statesville, NC 28677.
Dear Mr. Edwards :
George T. Everett, Ph.D.
Director
Subject: NPDES Permit Application
NPDES Permit No.NC0045012
Hill Haven Nursing Home
Iredell County
This is to acknowledge receipt of the following documents on March 6, 1990:
Application Form
Engineering Proposal (for proposed control facilities),
Request for permit renewal,
Application Processing Fee of $100.00,
Other ,
The items checked below are needed before review can begin:
Application Form ,
Engineering proposal (see attachment),
Application Processing Fee of
Delegation of Authority (see attached)
Biocide Sheet (see attached)
Other
If the application is not made complete within thirty (30) days, it will be
returned to you and may be resubmitted when complete.
This.application has been assigned to Jule Shanklin
(919/733-5083) of our Permits Unit for review. You will e advised of any
comments recommendations, questions or other information necessary for the
review of the application.
I am, by copy of this letter, requesting that our Regional Office
Supervisor prepare a staff report and recommendations regarding this
discharge. If you have any questions regarding this applications,
please contact the review person -listed above.
Sincerely,
M. Dale Overcash, P.E.
CC. Mooresville Regional Office
Pollution Prevention Pays
I
P.O. Box 27687, Raleigh, North Carolina 27611-7687 Telephone [phone]
i
An Equal Opportunity Affirmadve Action Employer

. eh- Div • a 39�
6-6
is -
90
NORTH CAROLIKA DEPT. OF NATURAL RESOURCES ARD M UNITY DEVELOPREW
ENVIRONMENTAL MAKAGEMENT CG4MISSION
MATIONPI POLLUTANT DISCHARGE ELIMINATION SYSTEM
APPLICATION FOR PERMIT TO DISCHARGE SHORT FORD D -\ FOR
r
To be filed only by service:, uhoik:sele .end retail tr6&,,
and other co rcial est&bIisiments including vessels'
y wf.�Y
d USE
�b
On not att apt to couplete this Forte taithout reading tl,? acCtsmp�anyinq Instructions
Please print or typo
1. 14amz, address, and tole/ rn1y n r of facility
/producing discharge
A. ae C1 i/ /7 u F,'__r/YLI 1�sJ�(� b/�4_'-- B. Street address" — �o X3 'Y
C. C i ty - 2z'-i
E . county `--
G. Telaphcne 10. `d 7�_ ' / 76 0a
Area
Co d2
2. SIC
(Leave blank)
IC�ATI�4 6rdmibEA
er'v
DATE RECEIVED
bE DAY
i Rif
4.
,D
fa 2 '1990
o. Sta2a �/J_ e
0C. ZIPS 7 _
f1 r
"ERMITS & ENC.II1cEit1NG
r
3. wmber of c-•employees
4. Mature of business
5. (a) ;heck here if' discharge occurs all year or
(b) Check the Mnth(s) discharge occurs:
I,oJanuary 2.®February 3.0XBrCh ,aril 5,C2NO
6.oJune 7.oJuly 6,0Au5Ust 9.0Sap t r 10.®Cxta r
11 . 0 November 12.0 D* cwbe r
(c) How many days per week:
2.0 2-3 3.0 4-5 4,0 6-7
.t 1..5.w....., A fn �Iirfnr&':�At.-rs oe,ly (check as anlieable)
t9ol> ti;cated before
Floc, 5allorrs tsar t rating 1 v
discKami". (percent)
Disch,argeogerating Per
D,1-�19
1 10-4999
" -S9°r9
10,00'0-
50,000
F
0.1-
m-
65-
95-
pperating day
g9,4
or more
29.9
64.9
94.9
IOG
(1)
(2)
(3)
�.
(7)
(8)
(9)
(10)
A. Sanitary, daily
average
B. Cooling water, etc.,
daily average
C. Other discharpe(s),
daily average;
Specify
D. Ha:lmum per ogerat-
ing day for comtined
I
dIscnnrge (all types)

7. If any of that types of t4ste identified in it&m G. eit'.r1;'-.r trrsatod
treated, ara disciaorg&d to plan -es ot"r t4m &urface czt nr dUaCk l lP-
as applicable.
Taste water is discharged to:
A. Vi,nir_ipal %cxa•r Systez
It• tlnil,•r�lr•tuurri an'll
C, ca t.ic' tank
U. Evaporation lagoon or Pc1nd
E. Other, specify:
0.1-9"
(2) 6 (3). I. .(4) 1 (5)
8. htsaber of discharge points:.
discharoints:
& A. '1/B. 02-3 C.o 4-5 D.0 6 or none
t/
9. Clara° of receiving water or waters
A. .10. Does your discharg-e contain or is it possible for your diacharV to Contain
one or w ra of the following substances Q as m result of r o ratsca,s,
activities, or processes: aria, cy&A &' alLM5�. baryllita86c®il &ad
1
chromit�t, copper, lsod, wrcu , wickQl, selanitaa, sitaC,
grease, and chlorine (residual ).
A. Cl yss B, no
1 certify that I am faa lliar with thQ informWO8 ccntaivted in tie W9lieaticn��
that to the best of my krtcsv'1�3 avid k31ief such WOM00 is tvQ, eW�lec,
accurate.
Printed a of Person Signing
(i1Q� �tjJ a 0. 11 F-------------
Title
Date t,Pplication Signed
Sigmtur9 of dkglic to .
>rorth` Carolina Gtix��ral Statute 14.3-215.6(b) (2) ���roo..v�ides th&t: A.tty pj,,rg= Tito Ix�ingly zax
any false statement representation, or c9rCcat3.on� appli.er�®'rQrrord, rraport, p?
or, other doct�nt rep rag regtaired to be maintained under Axticle 21 or rtagulations of the
Envirvtsaaental Ma=genant Co=aissf�roat i=pleman. .tas that Articles dr o falsifies, to ors �'
method required to be
or knosaly rendersin.accurata any x�c®rd ink or aitc� or qa q�p,�mQ
nYerated or maintained under Ayt�a$e 21.-oir• revAltiMs •ay the "snrr+brp�i�i,tl1 w pm=t Co
op'_enenting that APticle, Khali 'be ' > tV, .Q ` Migdgma-dole pLmishable b7 a -fine spot to exc
S10,nnn, or by imprisonM4W_' not to e7caad six wnthO, or by both. (18 U.S.C. Section 1051 p
a punis`�e^t by a fine of"Mot More $10,000 or r.�pri�t t not norm, tharr. 5 years, or b
Sin-ilar offense.)

t.,jiESiii1F"CES•AiVD
P€DRRUNITY �F7 sI QP37�i T
MAR 0 0 1990
State of North Carolina VNIS101f F [;: ,"
Department of Environment, Health, and Natural Rl� iar,:
Division of Environmental Management
512 North Salisbury Street • Raleigh, North Carolina 27611
James G. Martin, Governor
William W. Cobey, Jr., Secretary
March 8, 1990
Ms. Pamela Edwards
Administrator
Hill Haven Skilled Nursing and .
Rest Home
Route 16, Box 38
Statesville, NC 28677
George T. Everett, Ph. D.
Director
Subject: NPDES Permit Application
NPDES Permit No. NCO045012
Hill Haven Skilled Nursing and
Rest Home
Iredell County
Dear Ms. Edwards:
On March 6, 1990, the Division of Environmental Management received a NPDES
Permit Application for the subject facility. The application is considered incomplete. Therefore,
the Division of Environmental Management is returning the application.
The returned information must be resubmitted with the following to complete the
application:
1 . A check for $100.00 made payable to the NC Department of EHNR.
2. The application and supporting information must be submitted in triplicate.
The Division of Environmental Management will initiate the permit review process
upon receipt of the above requested information. The receipt of the above information does not
preclude this Division from requesting additional information at a future date.
If you have any questions, please contact me at [phone].
cc:Mooresville_ Regional=_Office
Sincerely,
AM2 Over -cash,,
Supervisor, NPDES Permits
Pollul ion Prevention Pays
P.O. Box 27687, Raleigh,.North Carolina 27611-7687 'Telephone [phone]
An Equal Opportunity Affirmative Action Employer

..
DF%2002 09:29:27
TERMINAL
CONNECTED
TO IM%/V%
IM%
KEX88/MP
03/22/90
COMPLIANCE
EVALUATION
ANALYSIS
REPORT
PAGE i
PERMIT--NCO045012
PIPE--801
REPORT
PERIOD: 8902-9001
LOC---
E
FACILITY--HILLHAVEN
NURSING HOME
DESIGN
FLOW--
.Oi8O
CLA%%--i
`OCATION--%TATE%VILLE
REGION/COUNTY--03
IREDELL
50050
0000
00530
00610
3i616
50060
000iO
00400
MONTH
Q/MGD
BOD
RE%/T%%
NH3+NH4- FEC
COLI CHLORINE
TEMP
PH
"IMIT F
.0180
F 30.00
F 30.0
NOL F
100O.0
NOL
NOL
9.0 6.0
02
.0080
2.40
2^i
.60
.O
.800
13.00
5.7-5.61---*
03 `
^OO8O
4.8O`LE%%THAN
LE%%THAN
4.0
.900
15.00
6.8-6.8
O4
.0080
'
ii.40
3.O
3^6O
.O
i.O8O
i8.00
6.7-6.7
05
`
.0080
2.iO
7.2
i.10
.O
.890
22.00
6.5-6.5
139/06
1
.0080
3.60
1.8
1.60
47.0
1.480
26.00
6.8-6.5
07
.0088
6.30
i7.6
1.90
ii2.O
.900
26.00
6.8-6.5
08
.0080
3^85
3.2
.9O
4.0
WO0
26.50
6.8-6.8
'
/09
.0080
i.50
6.0
i.8O
i.05O
26.00
6.9-6.5
.
9/i O
.0080
.
10.60
i O.O
4.55
W.O
.800
22.00-
7^0-7.0
'
9m
i
.008O
9.6O
5.5
4.00
35.0
.900
17.00
7.1-6.8
`
902
.0080
9.45
7.0
7.60
~
283.0
i.00O
i2.00
7.0-6.9
O/Oi
.0080
7.i0
i.O
'
2O.O
.900
-
12.00
7.0-7.O
WERAGE
�
.O08O
6.05
518
3.98
247.0
1.000
19.62
AXIMUM
.0080
ii.40
17.6
16.20
i776.0
1.480
26.50
7.100
INIMUM.
.008o
1.50
LE%%THAN
LE%%THAN
.O
.88O
i 2^0O
5.60O
,'NIT
MGD
MG/L
MG/L
MG/L
4/100ML
MG/L
DEG.0
%U

SRANDR.SSE
(2/13/90)
Date: q9 n
r
NPDES STAFF REPORT AND RECOMMENDATIONS
County: eci e- I
NPDES Permit No.: fyC, o04 aU 12-
PART I - GENERAL INFORMATION
1. Facility and Address: P," l(
- -,, sv ; l 4, NK I/q
2. Date of Investigation: iv'10�vvG_ Z 2, , t �tq0
3. Report Prepared By: P\
4. Perspn Contacted and Tele hone Number:
5.
6. Discharge Point - Latitude: 35� 441
Longitude: ? o 6 -,' 4,� '
Attach a USGS Map Extract and indicate treatment plant site
and discharge point on map.
USGS Quad No.:
7. Size (land available for expansion and upgrading):
A [1 �,'11
JCS "4 3 r
8. Topography (relationsh.p to flood plain included):
a
T.nr-At-inn of NParPgt T)We1 7 i_na:

10. Receiving Stream or Affected Surface Waters (?i �1-,v �,•,-�,�
a.
b.
c.
Classification: U0,5:s `
River Basin and Subbasin No.: ��f,��1`cv✓� 0�~ O�l-O
fPat'71rP.-, and pertinent
PART II - DESCRIPTION OF DISCHARGE AND -TREATMENT WORKS
1. type of Wastewater: loo o Domestic
o Industrial 1
a. Volume of Wastewater: m O re MGD
b. Types and quantities of industrial wastewater:
N
C. Prevalent toxic constituents in wastewater:
d. Pretreatment Program (POTWs only):
2. Production Rates (industrial discharges only) in Pounds:
3. Description of Industrial Process (for industries only) and
Applicable CFR Part and Subpart: KG
4. Type of,Treatment ( pecify whether proposed or existing):
U�J.i.2�.�
�J)
5. Sludge Handling and Disposal Scheme: V,,,06, -Q A fti�
6. Treatment Plant Classification: C k,5
7. SIC Code (s) :�`�l
Wastewater Code(s): ��

PART III - OTHER PERTINENT INFORMATION
1. Is this facility being constructed with Construction Grants
Funds (municipals only)? &/Z
2— Special monitoring requests: ti�b
3. Additional effluent limits requests: �e
4. Other:
PART IV - EVALUATION AND RECOMMENDATIONS

Y..
Signature of Report Preparer
Water Quality Regional Supervisor

r
PERMIT NO.: NCO045012
PERM1TTEE NAME:
NPDES WASTE LOAD ALLOCATION
Hill Haven Skilled Nursing Home / Hill Haven
Facility Status: Existing
Permit Status: Renewal
Major
Pipe No
001
Minor
Design Capacity: 0.018 MGD
Domestic (% of Flow): 100 %
Industrial (% of Flow): 0 %
Comments:
Possible MBAS ?
STREAM INDEX: 12-108-20-4
Q IDgPT. OF NATUP
1
RECEIVING STREAM: an unnamed tributary to Third Creek
Class: C
Sub -Basin: 03-07-06
Reference USGS Quad: E15NW, Troutman (please attach)
County: Iredell
Regional Office: Mooresville Regional Office
Previous Exp. Date: 11/30/90 Treatment Plant Class: I
Classification changes within three miles:
>25 miles; UT -> Third Creek -> Fourth Creek -> Yadkin River = C.
Requested by
Prepared by:
Reviewed by
Date: 3/13/90
Date: -1
Date: 0 D
Modeler
ec.
#
s
L-3k,
Drainage Area (mi L) 0- - 3a
Avg. Streamflow (cfs): 2 30
7Q10 (cfs) 0.3o Winter 7Q10 (cfs) t7.5o 30Q2 (cfs) p,-7p
Toxicity Limits: IWC 8 % Acute Chronic
Instream Monitoring: No
-4
Parameters
Upstream Location
Downstream Location
Effluent
Characteristics
Summer
Winter
BOD5 (mg/1)
NH3-N (mg/1)
D.O. (mg/1)
--
TSS (mg/1)
3o
30
F. Col. (/100 ml)
pH (SU)
_ 9
L[-14.9D
(; . C', 4Jl �',
tA- ^ ,
/10AWY\
�- MAX J
Comments: CoMGuANC6 DATA wy is rei> PosS i B l r 1>190r31,EM 01T4
C Lor4NE -rox.iC,TY- FACILITY W11- p_t`CEIII6 LgTTE2 4kLgE20 r PMBtg
* R� cAbrA14 ro• Cv�.cMCC PAZ4 FAclLlry dAAr MGar LtAnr T,'ro WZTECT
A"(AtS,r AwwVA11A ToXidITy 1AlSrAe.4A4.. F�et2,w'rM-E SHvuLD R&GE LYE 04or
zE-rvieW AAA AvAomA LIMIT vX WHoLro EFF. ToY, Llvw-r-

N C
Request No .: 5%"
------------------- WASTELOAD
ALLOCATION APPROVAL
1,S0or
JL, �tTUR:fL
FORM ---- ------�
Facility Name:
Hill Haven Skilled
Nursing Home
1g90
NPDES No.:
NC0045012
A-?/"17N
Type of Waste:
yp
Domestic
Cf
Status:
Existing/Renewal
Hr
Receiving Stream:
UT Third Creek
pFf�CE
Classification:
C
Subbasin:
03-07-06
Drainage area: 2.300 sq mi
County:
Iredell //����11
Summer 7Q10: 0.30 cfs
Regional Office:
Mooresville AA
Winter 7Q10: 0.50 cfs
Requestor:
Jule Shanklin
Average flow: 2.30 cfs
Date of Request:
3/13/90
30Q2: 0.70 cfs
Quad:
E15NW
-------------------- RECOMMENDED EFFLUENT LIMITS ----------- --------------
EXISTING
PROPOSED
summer winter
Wasteflow (mgd):
0.018
0.018
BOD5 (mg/1) :
30
30
** NH3N (mg/1) :
9. 4 (DAit.q MAX) 30 (PA)L-y MAX)
TSS (mg/1) :
30
30
Fecal coliform (#/100ml):
1000
200
pH (su) .
6-9
6
** Toxicity Testing Req.:
Chronic Q P/F: 80
i�p0. g 1991:
---------------------------- MONITORING----------------afiE!tt�'E_------
Li
Upstream (Y/N): N Location:
Downstream (Y/N): N Location:
----------------------------- COMMENTS -------- ---------------------------
Permittee had one violation of fecal coliform limit in 1989. Other limited
parameters were within requirements. Compliance data indicated possible
problem with Chlorine toxicity -facility will receive letter addressing the
problem.
**According to compliance data, facility can meet limits to protect
against ammonia toxicity instream. Therefore, permittee should receive the
choice between an ammonia limit or a whole effluent toxicity limit as
specified above.
Recommended by: �.G,p�,�, Date :
Reviewed by
Tech Support Supervisor:
Regional Supervisor:
Permits & Engineering:
Date: S
j 03 J�
Date:
Date: Yw�w
RETURN TO TECHNICAL SERVICES BY: APR 211990

8/89
Facility Name ail w OAVeAl IAJcLtLS�Nt� Ho�tt� Permit # /0G©04'5a! Z
CHRONIC TOXICITY TESTING REQUIREMENT (QRTRLY)
The effluent discharge shall at no time exhibit chronic toxicity in any two consecutive toxicity tests,
using test procedures outlined in:
1.) The North Carolina Ceriodaphnia chronic effluent bioassay procedure (North Carolina Chronic
Bioassay Procedure.- Revised *June 1988) or subsequent versions.
The effluent concentration at which there may be no observable inhibition of reproduction or
significant mortality is -0 % (defined as treatment two in the North Carolina procedure
document). The permit holder shall perform quarterly monitoring using this procedure to establish
compliance with the permit condition. The first test will be performed after thirty days from
issuance of this permit during the months of AAA, -Tint Sri, Pae . Effluent
sampling for this testing shall be performed at the NPDES permitted final effluent discharge below
all treatment processes. -
All toxicity testing results required as part of this permit condition will be entered on the Effluent
Discharge Monitoring Form (MR-1) for the month in which it was performed, using the parameter
code TGP3B. Additionally, DEM Form AT-1 (original) is to be sent to the following address:
Attention: Environmental Sciences Branch
North Carolina Division of
Environmental Management
P.O. Box 27687
Raleigh, N.C. 27611
Test data shall be complete and accurate and include all supporting chemical/physical measurements
pe.rfomled in association with the toxicity tests, as well as all dose/response data. Total residual
chlorine of the effluent toxicity sample must be measured and reported if chlorine is employed for
disinfection of the waste stream.
Should any single quarterly monitoring indicate a failure to meet specified limits, then monthly
monitoring will begin immediately until such time that a single test is passed. Upon passing, this
monthly test requirement will revert to quarterly in the months specified above.
Should any test data from this monitoring requirement or tests performed by the North Carolina
Division of Environmental Management indicate potential impacts to the receiving stream, this
permit may be, re -opened and modified to include alternate monitoring requirements or limits.
NOTE: Failure to achieve test conditions as specified in the cited document, such as minimum
control organism survival and appropriate environmental controls, shall constitute an invalid test
and will require immediate retesting(within 30 days of initial monitoring event). Failure to submit
suitable test results will constitute noncompliance with monitoring requirements.
7Q10 0.3o cfs
Permited Flow o , of I3 MGD
IWC% 8. 4 9
Basin & Sub -basin 03a7 0G ( 1100�
Receiving Stream (4r TliaD nmK
County XPeta-u.
Recommended by:
Date �/5 0
**Chronic Toxicity (Ceriodaphnia) P/F at `� %, MAR, Jum, Sey, Dec, See Part Z1, Condition .
V+ N43/ox c4v[cc

it
State of North Carolina
Department of Natural Resources and Community Development
Division of Environmental Management
512 North Salisbury Street • Raleigh, North Carolina 27611
James G. Martin, Governor December 2. 1985 R. Paul Wilms
S. Thomas Rhodes, Secretary Director
Ms. Dorothy S. Edwards
Hillhaven Nursing Home
Route 10, Bog 401
Statesville, NC 28677
Subject: Permit No. NCO045012
Hill Haven Nursing Home
Ired,ell C;o'un`tV
Dear Ms. Edwards:
In accordance with your application for discharge permit received on
March 22, 1985, we are forwarding herewith the subject State - NPDES
permit. This permit is issued pursuant to the requirements of North
Carolina and the US Environmental Prote-ctiou Agency dated December 6,
1983.
If any parts, requirements, or limitations contained in this permit
are unacceptable to you, you have the right to an adjudicatory hearing
before a hear-ing officer upon written demand to the Director within 30
days following receipt of this permit, identifying the specific issues to
be contended. Unless such demand is made, this permit shall be final and
binding.
Please take notice that this permit is not transferable. Part II,
B.2. addresses the requirements to be followed in case of change in
ownership or control of this discharge.
This .per-mit does not affect the legal requirement to obtain other
permits which may be required by the Division of Environmental
Management.. If you have any questions concerning this permit, please
contact Mr. Mack Wiggins, at telephone number 919/733-5083.
Sincerely,
L;1-,t.: .---. ,
IOC R. Paul Wilms
N• C. DY"-n. GF NATURAL
Pi ^CiU E,L.S AND
!�:® UZ.i1
zy 'IV --
L01'UEN1T
v =i
cc:
cc: Mr. Jim Patrick EPA
Pollution Prevention Pays
P.O. Banc 27687, Raleigh, North Carolina 27611-7687 Telephone [phone]
An Equal Opportunity Affirmative Action Employer

Permit No. NCO045012
STATE OF NORTH CAROLINA
DEPARTMENT OF NATURAL RESOURCES & COMMUNITY DEVELOPMENT V
DIVISION OF ENVIRONMENTAL MANAGEMENT
7
P E R M IT
To Discharge Wastewater Under The
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provisions 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,
Hill Haven Nursing Home
is hereby authorized to discharge wastewater from a facility located
at
Barium Springs
Iredell County
to receiving waters designated as an unnamed tributary to Third Creek
in the Yadkin River Basin .
in accordance with effluent limitations, monitoring requirements, and
other conditions set forth in Parts I, ZI, and III hereof.
This permit shall be effective December 1, 1985
This permit and the authorization to discharge .shall expire at
midnight on November 30, 1990
Signed this day of December 2, 1985
ORIGINAL SIGNED BY
OTHUR NIOUBERRY
FOR
i
R. Paul Wilms, Director
Divi-lion of Environmental Management
By Authority of the Environmental
Management Commission
i

Permit No. NC0045012
SUPPLEMENT TO PERMIT COVER SHEET
Hill Haven Nursing Home
is hereby authorized to:
1. Continue to operate disinfection facilities and a
wastewater treatment facility consisting of two septic
tanks and two surface sand filters located at Barium
Springs in Iredell County (See Part III, condition No.
B. of this Permit) , and
2. Discharge from said treatment works into an unnamed
tributary to Third Creek which is classified Class "C"
waters in the Yadkin River Basin.

3
A. EF"FLUENTLIMITATIONS AND MONITORING REQUIREMENTS Final
During'the period beglnnin9on
the effective date of the Permitand lasting until expiration,
. the permittee is authorized to
discharge from outfall(s) serial
number(s) 001.
Such discharges shall be limited and monitored by the permittee
as specified below:
Effluent tharacterlsti•es Discharge
Limitations
Monitoring
Requirements
K d bs d
Other•Units (Specify)
Measurement
5�1e
* S�1—e-
Monthl-7yg. -AlVg.
Montt a g.
regueng►
��e
Location
Flaw
0.018 MGD
Weekly Instantaneous
I or E
BOD,.5Day, 200C
30.0 mg/1 45.0 mg/1
2/Month
Grab
E
Total Suspended Residue
30.0 mg/l 45.0 mg/l
2/Month
Grab
E
NH as N.
Monthly
Grab
E
Fetal Coliform (geometric mean)
1000.0/100 ml 2000.0/100 ml
2/Month
Grab
E
Residual Chlorine
Daily
Grab
E
Temperature
Weekly
Grab
E
The pH.shall not be less than
6.0 standard'units'nor. greater than 9:0 standard units:and n c
shall be monitored 2/Month at the effluent by grab -sample. N o
There shall be no discharge of floating solids or visible foam. in other than trace amounts. i,

Part I
Permit No. NC
B. SCHEDULE OF COMPLIANCE
1. The permittee shall achieve compliance with the effluent limitations
specified for discharges in accordance with.the following schedule:
i -
j 2. No later than 14 calendar days following a date identified in the above
schedule of compliance, the permittee shall submit either a report of
progress or, in the case of.specific actions being required by identified
dates, a written notice of compliance or noncompliance. In the latter
case, the notice shall include the cause of noncompliance, any remedial
actions taken, and the probability of meeting the next scheduled requirement.
1
M4&I4:

Part I
Permit No. NC
"Act" used herein means the Federal Water Pollution Control Act, As Amended.
"DEM" used herein means the Division of Environmental Management of the
Department of Natural Resources and Community Development.
"EMC" used herein means the North Carolina Environmental Management Commission.
C. M014ITORING AND REPORTING
1. Representative Sampling
Samples and measurements taken as required herein shall be representative
of the volume and nature of the monitored discharge.
2. Reporting
Monitoring results obtained during the previous-month(s) shall be
summarized for each month and reported on a Monthly Monitoring Report
Firm (DEM No. MR 1.0111.1, and 1.4% postmarked.no later than the
30th day following the completed reporting period.
The first report is due on Duplicate signed copies of
these, and all other reports required herein, shall be submitted to
the following address:
Division of Environmental Management
Water Quality Section
Post Office Box 27687
Raleigh, North Carolina 27611
3. Definitions
a. The monthly average, other than for fecal colifarm bacteria, is the
arithmetic mean of all.the composite samples collected in a one -
month period. The monthly average for fecal caliform bacteria is
the geometric mean of samples collected in a one -month period.
b. The weekly average, other than for fecal coliform bacteria, is the
arithmetic mean of all the composite samples collected during a
one -week period. The weekly average for fecal coliform bacteria
is the geometric mean of samples collected in a one -week period.
C. Flow, M3/day (MGD): The flow limit expressed in this permit is the
24 hour average flow, averaged monthly. It is determined as the
arithmetic mean of the total daily flows recorded during the calendar
month.
d. Arithmetic Mean: The arithmetic mean of any set of values is the
summation of the individual values divided by the number of individual
values.
M5

Part I
Permit No. NC
e. Geometric Mean: The geometric mean of any set of values is the
Nth root of the product of the individual values where N is equal
to the number of individual values. The geometric mean is equiva-
lent to the antilog of the arithmetic mean of the logarithms of
the individual values. For purposes of calculating the geometric
mean, values of zero (0) shall be considered to be one (1).
f. Composite Sample: A "composite sample" is any of the following:
(1.) Not less than four influent or effluent portions collected
at regular intervals over a period of 24 hours and composited
in proportion to flow.
(2), Not less than four equal volume influent or effluent portions
collected over a period of 24 hours at intervals proportional
to the flow.
(3) An influent or effluent portion collected continuously over
a period of 24 hours at a rate proportional to the flow.
g. Grab Sample: A "grab sample" is a single influent or effluent
portion which is not a composite sample. The sample(s) shall be
collected at the period(s) most representative of the total discharge.
4. Test Procedures
Test procedures for the analysis of pollutants shall conform to the EMC
regulations published pursuant to N. C. G. S. 143-215.63 et seq, The
Water and.Air Quality Reporting Act, and to regulations published pursuant
to Section 304(g), 33 USG 1314, of the Federal Water Pollution Control Act,
As Amended, and Regulation 40 CFR 136.
5. Recording Results
For each measurement or sample taken pursuant to the requirements of
this permit, the permittee shall record the following information:
a. The exact place, date, and time of sampling;
b. .The dates the analyses were performed; and
c. The person(s) who performed the analyses.
M F

PART I
Permit No. NC
6. Additional Monitoring by Permittee
If the permittee monitors any pollutant at the location(s) designated
herein more frequently.than required by this permit, using approved
analytical methods as specified above, the results of such monitoring
shall be included in the calculation and reporting of the values required
in the Monthly Monitoring Report.Form,(DEM No. MR 1.0, 1.1, and 1.4)
Such increased frequency shall also be indicated.- The DEM may require
more frequent monitoring or.the monitoring of other pollutants not
required in this permit by written notification.
7. Records Retention
All records and information resulting from the monitoring activities
required by this Permit including all, records of analyses performed and
calibration and maintenance of instrumentation and recordings from
continuous monitoring instrumentation shall be retained for a minimum of
three (3)- years, or longer if requested by the.Division of Environmental
Management'or.the Regional Administrator of the Environmental Protection
Agency.

PART II
Permit No. NC
A. MANAGEMENT REQUIREMENTS
1. Change in Discharge
All discharges authorized herein shall be consistent with the terms and
conditions of this permit. The discharge of any pollutant identified
in this permit more frequently than or at a level in excess of.that
authorized shall constitute a violation of the permit. Any anticipated
facility expansions, production increases, or process modifications which
will result in new, different, or - increased discharges of pollutants must
be reported by submission of a new NPDES application or, if such changes
will not violate the effluent limitations specified in this permit, by
notice to the DEM of such changes. Following such notice, the permit
may be modified to specify and limit any pollutants not previously limited.
2. Non compliance Notification
If, for any reason, the.permittee does not comply with or will be unable
to comply with any effluent limitation specified in this permit, the per
mittee shall provide the Division of Environmental Management with the
following information, in writing, within five (5) days of becoming aware
of such condition:
a. A description of the discharge and cause of noncompliance; and
b. The period of noncompliance, including exact dates and times; or,
if not corrected; the anticipated time the noncompliance is expected
.to continue, and steps being taken to reduce, eliminate and prevent
recurrence of the noncomplying discharge.
3. Facilities Operation
The permittee shall -at all times maintain in good working order and
operate as efficiently as possible all treatment or control facilities
or systems installed or used by the permittee. to achieve compliance with
the terms.and conditions of this permit.
4. Adverse Impact
The.permittee shall take all reasonable steps to minimize any adverse
impact to navigable waters resulting from noncompliance with any effluent
limitations specified in this permit,.including such accelerated or
additional monitoring as necessary to determine the nature and impact of
the noncomplying discharge.
5. Bypassing
Any diversion from or bypass of facilities necessary to maintain compliance
with the terms and conditions of this permit is prohibited, except (i) where
u n 6 r

PART II
Permit No. NC
unavoidable to prevent loss of life or severe property damage, or
(ii) where excessive storm drainage or runoff would damage any
facilities necessary for compliance with the effluent limitations
and prohibitions of this permit. The permittee shall promptly
notify the Water Quality Section of DEM in writing of each such
diversion or bypass.
6. Removed Substances
Solids, sludges, filter backwash, or other pollutants removed in the
course of treatment or control of wastewaters shall be disposed of in
a manner such as to prevent any pollutant from such materials from .
entering waters of the State or navigable waters of the United States.
7. Power Failures
In order to maintain compliance with the effluent limitations and
prohibitions of this permit, the permittee shall either:
a. In accordance with the Schedule of Compliance contained in Part I,
provide an alternative power source sufficient to operate the waste-
water control facilities;
or, if such alternative power source is not in existence, and no date for
its implementation appears in Part I,
b. Halt, reduce or otherwise control production and/or all discharges
from wastewater control facilities upon the reduction, loss,.or
failure of the primary source of power to said wastewater control
facilities.
8. Onshore or Offshore Construction
This permit does not authorize or approve the construction of any onshore
or offshore physical structures or facilities or the undertaking of any
work in any navigable waters.
M

PART II
Permit No. NC
B. RESPONSIBILITIES
1. Right of En�ry
The permittee shall allow the Director of the Division of Environmental
Management, the Regioral Administrator, and/or their authorized represen-
tatives, upon the presentations of credentials:
a. The enter upon the permittee's premises where an effluent source is'
located or in which any records are required to be kept under the
terms and conditions of this permit; and
b. At reasonable times to have access to and copy any records required
to be kept under the terms and conditions of this permit; to inspect
any mnnita ring equipment or monitoring method required in this permit;
and to sample any discharge of pollutants.
2. Transfer of Din ershllo or Control
This permit is not-rarsferable. In the event of any change in control
or ownership of ,a cilitie-s from which the authorized discharge emanates
or is conterpl-.ite a, the permi ttee shall notify the prospective owner or
controller by letter of the existence of this permit and of the need to
obtain a permit it the name of the prospective owner. A copy of the
letter shal he,fnnvarded to the Division of Environmental Management.
3. Availability of Renn-I is
Except for data determined to be confidential under N. C. G. S. 143-215.
3(a)(2) or Section 308 of the Federal Act, 33 USC 1318, all reports prepared
in accordance with the terms shall be available for public inspection at the
offices of the Division of Environmental Management. As required by the Act,
effluent data shall not be considered confidential. Knowingly making any
false statement on any such report may result in the imposition of criminal
penalties as provided fig; in N. C. G. S. 143-215.6(b)(2) or in Section
309 of the Federal Act.
4. Permit Modification
i
M10 &I9
After notice and opua rtunity for a hearing pursuant to N. C. G. S. 143-
215.1(b)(2) and . S. 14,1-21"'i.l(e) respectively, this permit may be
modified, suspendn=i, or revoked in whole or in part during its term for
cause including, .ut rot iir�ited to, the following:
a. Violation of any terns or conditions of this permit;
b. Obtaining this permit by misrepresentation or failure to disclose
fully l relevant facts; or
c. A change in any condition that requires either a temporary or
permanent reduction or elimination of the authorized discharge.

PART II
Permit No. NC
5. Toxic Pollutants
Notwithstanding Part II, B-4 above, if a toxic.effluent standard or'
prohibition (including any schedule of compliance specified in such
effluent standard or prohibition) is established under Section 307(a)
of the Act for a toxic pollutant which is present in the discharge and
such standard or prohibition is more stringent than any limitation for
such pollutant in this permit, this permit shall be revised or modified
in accordance with the.toxic effluent standard or prohibition and the
permittee so notified.
6. Civil and Criminal Liability
Except as provided in permit conditions on "Bypassing" (Part II, A-5)
and "Power Failures" (Part II, A-7), nothing in this permit shall be
construed to relieve the permittee _from civil or criminal penalties for
noncompliance pursuant to N. C. G. S. 143-215.6 or Section 309 of the
Federal Act, 33 USC 1319.
7. Oil and Hazardous Substance Liability
RP
a
Nothing in this permit shall .be construed to preclude the institution
of any legal action or relieve the permittee from any -responsibilities,
liabilities, orpenalties to which the permittee is or may be subject
under N. C. G. S. 143-215.75 et seq. or Section 311 of the Federal Act,
33 USC 1321.
Property Rights
The issuance of this permit does not convey any property rights in either
real or personal property, or any exclusive privileges, nor does it
authorize any.injury to private property or any invasion of personal
rights, nor any infringement of Federal,State or local laws or regulations.
Severability
The provisions of this permit are severable, and if any provision of this
permit, or the application of any provision of this permit to any circum-
stance, is held invalid, the application of such provision to other cir-
cumstances, and the rem4inder of this permit shall not be affected thereby.

PART II
Permit No NC
10. Expiration of Permit
Permittee is not authorized to discharge after the expiration. date.
In order to receive authorization to discharge beyond the expiration
date, the permittee shall submit such information, forms, and fees as
are required by the agency authorized to issue permits no later than 180
days prior to the expiration date. Any discharge without a permit after
the expiration will subject the permittee to enforcement procedures as
provided in N. C. G. S. 143-215.6 and 33 USC 1251 et seq..
11

Part III
Permit No. NC
A. Previous Permits
All previous State water quality permits issued to this facility,
whether for construction or operation or discharge, are hereby revoked
by issuance of this permit. The conditions, requirements, terms, and
provisions of this permit authorizing discharge under the National
Pollutant Discharge Elimination System governs discharges from this
facility.
B. Construction
No construction of wastewater treatment facilities or additions thereto
shall be begun until Final Plans and Specifications have been submitted
to the Division of Environmental Management and written approval and
Authorization to Construct has been issued. If no objections to final
plans and specifications have been made by the Division of Environmental
Management within 60 days following acknowledgement that a complete set
of final plans and specifications has been received, the plans may be
considered approved and construction authorized.
C. Certified Operator
Pursuant to Chapter 90A of North Carolina General Statutes, the permittee
shall employ a certified wastewater treatment plant operator in responsible
charge of the wastewater treatment facilities. Such operator must hold a
certification of the grade equivalent to the classification assigned to
the wastewater treatment facilities.
D. Groundwater Monitoring
The permittee shall, upon written notice from the Director of the Division
of Environmental Management, conduct groundwater monitoring as may be
required to determine the compliance of this NPDES permitted facility
with the current groundwater standards.
M15 & I12

�V
J, Permit No. NCO045012
i
V
STATE OF NORTH CAROLINA DEPARTMENT OF ENVIRONMENT, HEALTH, AND NATURAL RESOUACQ
�� (a� DIVISION OF ENVIRONMENTAL MANAGEMENT Atnz 1,� $1M'aAt-
PERMIT
TO DISCHARGE WASTEWATER UNDER THE p�yisrorr Q ! 1990
NATIONAL POLLUTANT DISCHARGE ELIMINATION
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,
Hill Haven Skilled Nursing Home
is hereby authorized to discharge wastewater from a facility located at
Hill Haven Nursing Home
Hill Haven Road (NCSR 1381 )
Barium Springs
Iredell County
to receiving waters designated as an unnamed tributary to Third Creek in the Yadkin -Pee Dee River
Basin
in accordance with effluent limitations, monitoring requirements, and other conditions set forth in
Parts I, H, and III hereof.
This permit shall become effective
This permit and the authorization to discharge shall expire at midnight on July 31, 1994
Signed this day
George T. Everett, Director
Division of Environmental Management
By Authority of the Environmental Management Commission

Permit No.
SUPPLEMENT TO PERMIT COVER SHEET
Hill Haven Skilled Nursing Home
is hereby authorized to:
NC0045012
�• C.
R
C�3g gr, R AN UR4L
A�r,r 1
1 1990
PIVISI;,ja Pf rNVl;?Jrlr,
b9u0,?FS�.I��E RfGIJ�AI pFflCf.
1. Continue to operate an existing 0.018 MGD wastewater treatment facility consisting of two
septic tanks with two surface sand filters and effluent chlorination located at Hill Haven Nursing
Home, Hill Haven Road (NCSR 1381 ), Barium Springs, Iredell County (See Part III of this
Permit), and
2. Discharge from said treatment works at the location specified on the attached map into an
unnamed tributary to Third Creek which is classified Class C waters in the Yadkin -Pee Dee
River Basin.

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✓� a�-� �v+''� 7.5 MINUTE SERIES (TOPOGRAPHIC)
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A. (). EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS SUMMER (April 1- October 31) Permit No. NCO045012
During the period beginning on the effective date of the permit and lasting until expiration, the Permittee is authorized to discharge from
outfall(s) serial number 001. Such discharges shall be limited and monitored by the permittee as specified below:
Effluent Characteristics
Flow
BOD, 5 day, 200C
Total Suspended Residue
NH3 as N**
Fecal Coliform (geometric mean)
Total Residual Chlorine
Temperature
Discharge Limitations
Monthly Avg. Weekly Avg., Daily Max
0.018 MGD
30.0 mg/I 45.0 mg/I
30.0 mg/I 45.0 mg/I
9.4 mg/I
200.0 /100 ml 400.0 /100 ml
* Sample locations: E - Effluent, I - Influent
Monitoring
Requirements
Measurement
Sample
*Sample
Frequency
Jype
Location
Weekly
Instantaneous
I or E
2/Month
Grab
E
2/Month
Grab
E
2/Month
Grab
E
2/Month
Grab
E
Daily
Grab
E
Weekly
Grab
E
The pH shall not be less that 6.0 standard units nor greater than 9.0 standard units and shall be monitored 2/month at the effluent by grab.
sample.
There shall be no discharge of floating solids or visible foam in other than trace amounts.
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A. (). EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS WINTER (November 1 - March 31) Permit No. NCO045012
During the period beginning on the effective date of the permit and lasting until expiration, the Permittee is authorized to discharge from
outfall(s) serial number 001. Such discharges shall be limited and monitored by the permittee as specified below:
Effluent Characteristics
Discharge Limitations
Monitoring
Requirements
Measurement
Sample
*Sample
Monthly Avg. Weekly Avg.
Daily Max
Frequency
LyRe
Locatlon
Flow
0.018 MGD
Weekly
Instantaneous
I or E
BOD, 5 day, 200C
30.0 mg/I
45.0 mg/I
2/Month
Grab
E
Total Suspended Residue
30.0 mg/I
45.0 mg/I
2/Month
Grab
E
NH3 as N**
30.0 mg/I
2/Month
Grab
E
Fecal Coliform (geometric mean)
200.0 /100 ml
400.0 /100 ml
2/Month
Grab
E
Total Residual Chlorine
Daily
Grab
E
Temperature
Weekly
Grab
E
* Sample locations: E - Effluent, I - Influent
The pH shall not be less that 6.0 standard units nor greater than 9.0 standard units and shall be monitored 2/month at the effluent by grab
sample.
There shall be no discharge of floating solids or visible foam in other than trace amounts.
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STAFF REPORT AND RECOMMENDATIONS
Part I - INSPECTION OF EXISTING WASTEWATER TREATMENT PLANT SITE
a. Place visited: Hill Haven Nursing Home
b. Mailing Address:. Rt. 10 Box 401
Statesville, N.C. 28677
2. Date of Investigation: August 29, 1985 Date of Report: September 4, 1985
3. By: Michael L. Parker, Environmental Engineering Tech. III
4. a. Persons contacted: Mr.Homer Edwards, operator
b. Phone No.: [phone]
5. Directions to site: From the community of Barium Springs in Iredell
County, travel north on Hwy. 21 approximately
1.75 miles and turn left on SR 1381 (Hill Haven Rd.).
Travel approximately 50 yards and the entrance to
Hill Haven Nursing Home.is on the.right side of SR 1381.
i
6. a. The coordinates to the.existing point of effluent discharge are:
Latitude: 350 44' 45"
Longitude: 800 53' 40"
b. USGS Quad No.: E15NW :;(see attached map)
7. Size (land available for expansion and upgrading): There is limited area
for any future expansion -less than one acre.
8. Topography: hilly 5 - 12% slopes - Treatment plant site has been landscaped
to reduce slope.
9. Location of nearest dwelling: several within 1000 feet of existing treatment
i plant.
10. Receiving Stream: U. T. to Third Creek
a. Classification: "C"
b. Minimum 7 - Day, 10 - Year discharge at site: 0.3 cfs
c. River Basin and Sub -Basin No.: Yadkin 030706
Part II - DESCRIPTION OF EXISTING TREATMENT:• FACILITIES
1. Existing Facilities: The existing Wastewater TreafinentIfacilities consist
of two septic tanks with a combined capacity of 18,000 gallons,
ftwo surface sand filters (one for each tank) with a surface
area of 3200 sq. ft., and effluent chlorination. The nursing
home contains '107 beds and at 150 gallons/bed the wastewater
generated should not exceed 16.,050 gallons per day.
2. Proposed Modifications: N/A

Page Two
Part III - EVALUATION AND RECOMMENDATIONS
I. Performance Evaluation: Samples taken during the site investigation
yielded the following results:
BOD5
TSS
Fecal coliform
PH
7.6 mg/l
4.0 mg/l
680,000/100 ml
6.5 S.U.
2. 0 & M Evaluation: Facility appeared to have uneven distribution over the
filter bed. The PVC filter lines were not level and it was noted
that a substantial amount of the filter bed area was not being
utilized. Some vegetation was growing on the bed but did not
appear detrimental to its_ operation. Chlorine was not being
monitored in the chlorinator.
3. Recommendations and/or Special Conditions: It is recommended that the
NPDES Permit for this facility be renewed.

CONSERVATION AND DEVELOPMENT /�!`1S/l% �,A�� TROUTMAN QUADRANGLE
IGH, NORTH CAROLINA �%!��-S�.UG e ¢�o NORTH CAROLINA
4855 /V SW l 7.5 MINUTE SERIES (TOPOGRAPHIC) �S�P
(STATESV/LLE WEST) 501
55' 508
� A79 s09 '•r �t�v:ei.[75ner s10 j7440000 FEET sll 80°52'30
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10 1 ;✓ o
35°45'
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pF ENV����M tpl n 1/
VO
Ir ,,
Statkof North Carolina
i Departin of Natural- Resources and Community Development
512-North Salisbury Street • Raleigh, North Carolina 27611
James C. Martin; C'.oNernoe �u Gw'� 2/ S. 'Lomas Rhodes, SecreurY
196ME ,OVA� AAr-
•
Subject: Application for WDES Peradtt No.
Dear �%%3 AQ 221Lf/ �S _ t� County :
Recelpt of the fdllowing docmoeats• is hereby adcnowledgea
Application -loll
Engineering Proposal (for proposed control facilities) _
- - -�Request for permit renewalOther
_8_aaS: D aPra
If. MW of the stew ' Usted below are checked, the PF receive& is ln-
COMPIete sad the IndicatedAtee(s) =sst be received before revtem can begin:
APP rtfon Fozae (=PLM enclosed)
Eagiaeeriag Proposal (See (b) 15 on attached) �/J� //--
T4YOt�74T0.
Zf .the. sPP a +od� is�.ao
'
acne oosplece .rtthln- be ret
w
thirty.3r. ill urned
l"°a and .� be _ (30 • 4mi, zaeibmitted when c mplete.
.M OPPlIcatiaa bar IN assigned
(9I9/733-3@gjj of am Permits Unit for-z+e�rsev and pre t of a draft permit..
Once- the -permit is drafted, public notice aft be 'issued for fast-fie,e (45) days
prior to first actfoa oa the Ssa 11.or denial of the Veadt- Tow aritl 6e advised
� its, rsoo Bang, questiong or other fafossttLom f _ the
VaVIAW of the opplfeE"On
I an, by COP! of this letter, regwating that am Offim Supervisor
Prepare a staff report and rs000eadstfoas any this
d�. Zf h�eve
_ tlds application. please contact the- re IAw person listed
Mouberry, P.E.
Supervisor, Permits and Eagiaeerittg
�`�- Regional Supervisor

HILL HAVEN SKILLED NURSING HOME AND REST HOME
ROUTE 10, BOX 401
STATESVIL:LE. NORTH CAROLINA 28677
PHONE [phone] OR 872-7602
July 30, 1985
Director
Division of Environmental Management
North Carolina Department of NRCD
P.O. Box 27687
Raleigh, N. C. 27611
Subject NPDES .Permit No. NC 0045012
ired`ell County i, N . C .
Dear Sir:
Please renew permit no. NC -0045012. There are no
expected changes in the nature or volume_ of the
waste..
Enclosed you -will find a check in the amount of
$25.00 for the cost of the permit.
Sincerely,]
Dorothy S_. Edwards
Administrator
DSE/pje
Enclosure
pERM�TS & ENGINEERING a,
f J

Permit No. NC0045012
STATE OF NORTH CAROLINA
DEPARTMENT OF NATURAL RESOURCES & COMMUNITY DEVELOPMENT
DIVISION OF ENVIRONMENTAL MANAGEMENT
P E R M I T
To Discharge Wastewater Under The
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provisions 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,
Hill Haven Nursing Home
is hereby authorized to discharge wastewater from a facility located
at
Barium Springs
Iredell County
to receiving waters designated as an unnamed tributary to Third Creek
in the Yadkin River Basin
in accordance with effluent limitations, monitoring requirements, and
...other conditions set forth in Parts I, II, and III hereof.
This permit shall be effective
This permit and the authorization to discharge shall. expire at
midnight on
Signed thi.s day of
0""RAFT
I
I
R. Paul Wilms, Director
Division -of .Environmental Management
By Authority of the Environmental
Management Commission
i

Permit No. NC0045012
SUPPLEMENT TO PERMIT COVER SHEET
Hill Haven Nursing Home
is hereby authorized to:
1. Continue to operate disinfection facilities and a
wastewater treatment facility consisting of two septic
tanks and two surface sand filters located at Barium
Springs in Iredell County (See Part III, condition No.
B. of this Permit), and
2. Discharge from said treatment works into an unnamed
tributary to Third Creek which is classified Class "C"
waters in the Yadkin River Basin.

X
A. (i). E'M'FIUENT LIMITATIONS AND MONITORING REQUIREMENTS Final
Wring the period 40inningon the effective date of the Permitand lasting Until expiration,
the perM WN is auri2ed to discharge from outfall(s) serial number(s) 001.
Such discharges shall be limited and monitored by the permitter as specified below:
Lrflueorh_C1acteM s�1 cs_ Discharge Limitations Ami tori n9 Ream rements
Kgjdjj s Other•Units (S ecify)
Monthly vg. WjqK1Y vg,_ Mont
Flow 0.018 MGD
BUD, 5Day, 200C 30.0 mg/1 45.0 mg/l
Total Suspended Residue' 30.0 mg/1 45.0 mg/1
NR as N .
Fegal Coliform (geometric mean) 1000.0/100 ml 2000.0/100 ml
Residual Chlorine
Temperature
*�agnple locations: E - Effluent, 1 - Influent
Measurement
Saxvle
* Sample
Frequency
��e
Localon
Weekly
Instantaneous
I or E
2/Month
Grab
E
2/Month
Grab
E
Monthly
Grab
E
2/Month
Grab
E
Daily
Grab
E
Weekly
Grab
E
The pN shall not be less than 6.0 standard units nor greater than 9.o standard units and
shall be monitored 2/Month at the effluent by grab sample.
There shall be no discharge of floating solids or visible foam in other than trace amounts.

DIVISION OF ENVIRONI EsNTAI, bWTAGE11ENT
Ms. Dorothy S.2dwards, Administrator
Hill Haven Nursing dome
Route 10, Box 401
Statesville, North Carolina 23677
Dear his. Edwards:
January 13, 1981
If
Subsect: Permit I' LSt 0 Q '%
?ill Havens sing dome
Iredell`County
In accordance with your application for discharge Permit received
.3anuary 31, 1979, we are forwarding herewith the subject State - NPDES Permit.
This Permit is issued pursuant to the requirements of North Carolina General
Statutes 143-215.1 and the Memorandum of Agreement between North Carolina
and the U. S. Environmental Protection Agency dated October 19, 1975.
If any parts, requirements, or limitations contained .in this Permit
are unacceptable to you, you have the right to an adjudicatory hearing before
a hearing officer upon written demand to the. Director within 30.days
following receipt of this Permit, identifying the specific issues to be
contended. Unless such demand is made, this Permit shall.be final and binding.
Please take notice that this Permit is not transferable. Part IT, B.2.
addresses the requirements to be followed in case of change in ownership or
control of this discharge.
This Permit does not affect the legal requirement to obtain other Permits
which may be required by the Division of Environmental Management. If you
have any questions concerning this Permit, please contact Mr. Bill Mills,
telephone [phone].
Fours very truly,
Original Signed -By
X C. URNAGC, JR.
itNeilS . Grigg
Director
cc: i r. George Harlow, EPA
,00reeville Regional Office
Mooresville Regional Office Manager

rermi L ivu. ivy is U t -S qj 12
STATE OF NORTH CAROLINA
DEPARTMENT OF NATURAL RESOURCES & COMMUNITY DEVELOPMENT
DIVISION OF ENVIRONMENTAL MANAGEMENT
�i 1
To Discharge Wastewater Under The NATIONAL
POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provisions 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
j Water Pollution Control Act, as amended,
Hill Haven Nursing Home
is hereby authorized to discharge wastewater from a facility located at
Barium Springs
Iredell County
td receiving waters
Unnamed Tributary to Third Creek in the Yadkin River Basin
in accordance with effluent limitations, monitoring requirements, and other
conditions set forth in Parts I, 11, and III hereof.
This permit shall become effective JAN i 01 119"
This permit and the authorization to discharge.shall expire at midnight
on
DEC 3 1 1985
Signed this day of JAN
Original Signed By
A. C. TURNAGE, JR.
Neil S. Grigg, Director
Division of Environmental Management
By Authority of the Environmental
Management Commission
M1 & Ii

Page of
Permit No. NCO 0 4 5 0 1 2
SUPPLEMENT TO PERMIT COVER SHEET
Hill Haven Nursing Home
is hereby authorized to:
1. Enter into a contract for construction of disinfection facilities,
2. Construct and operate disinfection facilities and continue to operate
a wastewater treatment facility consisting of two septic tanks, two
surface sand filters located at Barium Springs (Note Part III of this
Permit), and
3. Discharge from said treatment works into an unnamed tributary to Third
Creek which is classified "C".

A. (1): EFFLUENT.LIMITATIONS AND MONITORING REQUIREMENTS - FINAL
During the period beginning on the effective date and lasting until expiration,
the pe rmittee is authorized to discharge from outfall(s) serial number(s) 001.
Such discharges shall be limited and monitored by the permittee as specified below:
Effluent Characteristics Discharge Limitations Monitoring Requirements
Flow
BODS
x TSS
,x.Fecal Co- Iiform
pH
Dissolved Oxygen
Settleable Matter
Residual Chlorine
COD
NH3 as N
Total Residue
Temperature
*Sample Locations:
KK dal! (1 bsL) Other -Units (Specify)
Monthly Avg. Weekly, Avg. Mont y vg. ee y vg.
0.018 MGD
30 mg/l 45 mg/l
30 mg/l 45 mg/l
1000/100 ml 2000/100 ml
I -Influent, E-Effluent, U-Upstream, D-Downstream
Measurement
re Ile ency
Weekly
Semiannually
Annually
Semiannually
Quarterly
Monthly
Monthly
Monthly
Semiannually
Annually
Annually
Monthly
Sam le * Sample
Type Location
Instantaneous
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Grab
Grab
E
I,E,U,D
I,E
E,U,D
I, E, U, D-
E,U,D
E
E
E,U,D
I,E
I,E
E,U,D
The temperature of the effluent shall be such that it will not cause an increase in the temperature of the receiving stream
of more than 50F above ambient stream water temperature.
Ito -s
®q0C+
The pH shall not be less than 6.0 standard units nor greater than 9.0 standard units,
c�
►� o
o
There shall be no discharge of floating solids or visible foam in other than trace amounts.• ,

Part I
Permit No. NC
B. SCHEDULE OF COMPLIANCE
1. The permittee shall achieve compliance with the effluent limitations
specified for discharges in accordance with the following schedule:
2. No later than 14 6�lendar days following a date identified in the above
schedule of compliance, the permittee shall submit either a report of
progress or, in the case of specific actions being required by identified
dates, a written notice of compliance or. noncompliance. In the latter
case, the notice shall include the cause of noncompliance, any remedial
actions taken, and the probability of meeting the next scheduled requirement.
M4&I4

Part I
Permit No. NC
"Act" used herein means the Federal Water Pollution Control Act, As Amended.
"DEM" used herein means the Division of Environmental Management of the
Department of Natural Resources and Community Development.
"EMC" used herein means the North Carolina Environmental Management Commission.
C. MONITORING AND REPORTING
1. Representative Sampling
Samples and measurements taken as required herein shall be representative
of the volume and nature of the monitored discharge.
2. Reporting
Monitoring results obtained during the previous month(s) shall be
summarized for each month and reported on a Monthly Monitoring Report
Form (DEM No. MR 1.0, 1.1, and,1.4).` postmarked no later than the
45th day following the completed reporting period.
The first report is due on MAR 1 5 1981 . Duplicate signed copies of
these, and all other reports required herein, shall be submitted to
the following address:
Division of Environmental Management
Water Quality Section
Post Office Box 27687
Raleigh, North Carolina 27611
3. Definitions
a. The monthly average, other than for fecal coliform bacteria, is the
arithmetic mean of all the composite samples collected in a one -
month period. The monthly average for fecal coliform bacteria is
the geometric mean of samples collected in a one -month period.
b. The weekly average, other than for fecal coliform bacteria, is the
arithmetic mean of all the composite samples collected during a
one -week period. The weekly average for fecal coliform bacteria
is the geometric mean of samples collected in a one -week period.
c. Flow, M3/day (MGD): The flow limit expressed in this permit is the
24 hour average flow, averaged monthly. It is determined as the
arithmetic mean of the total daily flows recorded during the calendar
month.
d. Arithmetic Mean: The arithmetic mean of any set of values is the
summation of the individual values divided by the number of individual
values.
M5

Part I
Permit No. NC
e. Geometric'Mean: The geometric mean of any set of values is the
Nth root of the product of the individual values where N is equal
to the number of individual values. The geometric mean is equiva-
lent to the antilog of the arithmetic mean of the logarithms of
the individual values. For purposes of calculating the geometric
mean, values of zero (0) shall be considered to be one (1).
f. Composite Sample: A "composite sample" is any of the following:
(1) Not less than four influent or effluent portions collected
at regular intervals over a period of 24 hours and composited
in proportion to flow.
(2) Not less than four equal volume influent or effluent portions
collected over a period of 24 hours at intervals proportional
to the flow.
(3) An influent or effluent portion collected continuously over
a period of 24 hours at a rate proportional to the flow.
g. Grab Sample: A "grab sample" is a single influent or effluent
portion which is not a composite sample. The sample(s) shall be
collected at the period(s) most representative of the total discharge.
4. Test Procedures
Test procedures for the analysis of pollutants shall conform to the EMC
regulations published pursuant to N. C. G. S. 143-215.63 et seq, The
Water and Air Quality Reporting Act, and to regulations published pursuant
to Section 304(g), 33 USC 1314, of the Federal Water Pollution Control Act,
As Amended, and Regulation 40 CFR 136.
5. Recording Results
For each measurement or sample taken pursuant to the requirements of
this permit, the permittee shall record the following information:
a. The exact place, date, and time of sampling;
b. The dates the analyses were performed; and
C. The person(s) who performed the analyses.
M6

PART I
Permit No. NC
6. additional Monitoring by Permittee
If the permittee monitors any pollutant at the location(s) designated
herein more frequently than required by this permit, using approved
analytical methods as specified above, the results of such monitoring
shall be included in the calculation and reporting of the values required
in the Monthly Monitoring Report Form (DEM No. MR 1.0, 1.1, and 1.4)
Such increased frequency shall also be indicated. The DEM may require
more frequent monitoring or the monitoring of other pollutants not
required in this permit by written notification.
7. Records Retention
All records and information resulting from the monitoring activities
required by this Permit including all records of analyses performed and
calibration and.maintenance of instrumentation and recordings from
continuous monitoring instrumentation shall be retained for a minimum of
three (3) years, or longer if requested by the Division of Environmental
Management or the Regional Administrator of the Environmental Protection
Agency.
M7

PART aI
Permit No. NC
A. MANAGEMENT REQUIREMENTS
1. Change in Discharge
All discharges authorized herein shall be consistent with the terms and
conditions of this permit. The discharge of any pollutant identified
in this permit more frequently than or at a level in excess of that
authorized shall constitute a violation of the permit. Any anticipated
facility expansions, production increases, or process modifications which
will result in new, different, or increased discharges of pollutants must
be reported by submission of a new NPDES application or, if such changes
will not violate the effluent limitations specified in this permit, by
notice to the DEM of such changes. Following such notice, the permit
may be modified to specify and limit any pollutants not previously limited.
2. Non compliance Notification
If, for any reason, the permittee does not comply with or will.be unable
to comply with any effluent limitation specified in this permit, the per-
mittee shall provide the Division of Environmental Management with the
following information, in writing, within five (5) days of becoming aware
of such condition:
a. A description of the discharge and cause of noncompliance; and
b. The period of noncompliance, including exact dates and times; or,
if not corrected; the anticipated.time the noncompliance is expected
to continue, and steps being taken to reduce, eliminate and prevent
recurrence of the noncomplying discharge.
3. Facilities Operation
The permittee shall at all times maintain in good working order and
operate as efficiently as possible all treatment or control facilities
or systems installed or used by the permittee to achieve compliance with
the terms and conditions of this permit.
4. Adverse Impact
The permittee shall take all reasonable steps to minimize any adverse
impact to navigable wasters resulting from noncompliance with any effluent
limitations specified in this permit, including such accelerated or
additional monitoring as necessary to determine the nature and impact of
the noncomplying discharge.
5. Bypassing
Any diversion from or bypass of facilities necessary to maintain compliance
With the terms and conditions of this permit is prohibited, except (i) where
M8&I7

PART II
Permit No. NC
unavoidable to prevent loss of life or severe property damage, or
(ii) where excessive storm drainage or runoff would damage any
facilities necessary for compliance with the effluent limitations
and prohibitions of this permit. The permittee shall promptly
notify the Water Quality Section of DEM in writing of each such
diversion or bypass.
�. 6. Removed Substances
Solids, sludges, filter backwash, or other pollutants removed in the
course of treatment or control of wastewaters shall be disposed of in
a manner such as to prevent any pollutant from such materials from
entering waters of the State or navigable waters of the United States.
7. Power Failures
In order to maintain compliance with the effluent limitations and
prohibitions. of this permit, the permittee shall either:
a. In accordance with the Schedule of Compliance contained in Part I,
provide an alternative power source sufficient to operate the waste-
water control facilities;
or,if such alternative power source is not in existence, and no date for
its implementation appears in Part I,
b. Halt, reduce or otherwise control production and/or all discharges
from wastewater control facilities upon the reduction, loss, or
failure of the primary source of power to said wastewater control
facilities.
8. Onshore or Offshore Construction
This permit does not authorize or approve the construction of any onshore
or offshore physical structures or facilities or the undertaking of any
work in any navigable waters.

PART - II
Permit No. NC
B. RESPONSIBILITIES
I. Right of Entry
The permittee shall allow the Director of the Division of Environmental
Management, the Regional Administrator, and/or their authorized represen-
tatives, upon the presentations of credentials:
j a. 'The enter upon the permittee°s premises where an effluent source is"
located or in which any records are required to be kept under the
terms and conditions of this permits and
b. At reasonable times to have access to and copy any records required
to be kept under the terms and conditions of this permit; to inspect
any monitoring equipment or monitoring method required in this permit;
and to sample any discharge of pollutants.
2. Transfer of Ownership or Control
This -permit is not transferable. In the event of any change in control
or ownership of facilities from which the authorized discharge emanates
or is contemp±l�ated, the permittee shall notify the prospective owner or
controller by letter of the existence of this permit and of the need to
obtain a permit'in the name of the prospective owner. A copy of the
letter shall beJorwarded to the Division of Environmental Management.
3. Availability of Reports
Except.for data determined to be confidential under N. C. G. S. 143-215.
3(a)(2')`'or Section 308 of the Federal Act, 33 USC 1318, all reports prepared
in accordance with the terms shall be available for public inspection.at the
offices of the Division of Environmental Management. As required by the Act,
effluent data shall not be considered confidential. Knowingly making any
false statement on any such report may result in the imposition of criminal
penalties as provided for in N. C. G. S. 143�215.6(b)(2�) or in Section
309 of the Federal Act.
4. Permit Modification
After notice and opportunity for a hearing pursuant to N. C. G. S. 143-
215.1(b)(2) and G. S. 143-215.1(e) respectively, this permit may be
modified, suspended, or revoked in whole or in part during its term for
cause including, but not limited to, the following:
a. Violation of any terms or conditions of this permit;
b. Obtaining this permit by misrepresentation or failure to disclose
fully all -relevant facts; or
c.. A change in any condition that requires either a temporary or
permanent reduction or elimination of the authorized discharge.
M10&I9

PART II
Permit No. NC
5. Toxic Pollutants
Notwithstanding Part II, B-4 above, if a toxic effluent standard or
prohibition (including any schedule of compliance specified in such
effluent standard or prohibition) is established under Section.307(a)
of the Act for a toxic pollutant which is present in the discharge and
such standard or prohibition is more stringent than any limitation for
such pollutant in this permit, this permit shall be revised or modified
In accordance with the toxic effluent standard or prohibition and the
permittee so notified.
6. Ciyil and Criminal Liability
Except as provided in permit conditions on "Bypassing" (Part II, A-5)
and "Power Failures" (Part II, A-7), nothing in this permit shall be
construed to relieve the permittee from civil or criminal penalties for
noncompliance pursuant to N. C: G. S. 143-215.6 or Section 309 of the
Federal Act, 33 USC 1319.
7. Oil and Hazardous Substance Liability
Nothing in this permit shall be construed to preclude the institution
of any legal action or relieve the permittee from any -responsibilities,
liabilities, or penalties to which the permittee is or may be subject
under N. C. G. S. 143-215.75 et seq, or Section 311 of the Federal Act,
33 USC 1321.
8. Property Rights.
The issuance of this permit does not convey any propertyrights in either
real or personal property, or any exclusive privileges, nor does it
authorize any injury to private property or any invasion of personal
rights, nor any infringement of Federal,State or local laws or regulations.
9. Severability
The provisions of this permit are severable, and if any provision of this
permit, or the application of any provision of this permit to any circum-
stance, is held invalid, the application of such provision to other cir-
cumstances, and the remdinder of this permit shall not be affected thereby.

PART II
Page of
Permit No NC
10. Expiration of Permit
Permittee i's riot authorized to discharge after the expiration date.
In order to receive authorization to discharge beyond the expiration
date, the permittee shall submit such information, forms, and fees as
are required by the agency authorized to issue permits no later than 180
days prior to the expiration date. Any discharge without a permit after
the expiration will subject the permittee to enforcement procedures as
provided in N. C. G. S..143-215.6 and 33 USC 1251 et seq..
T
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STAFF REPORT AND RECOMMENDATIONS
Part I - INSPECTION OF WASTEWATER TREATMENT PLANT SITE
1. Place visited: Hill Haven Nursing Home
Iredell County
2. Date: May 6, 1980
3. By: David T. Adkins
4. Person contacted: Mr. Homer Edwards, Operator
5. Directionsto site: Travel U. S. Highway 21 north from Barium Springs.
to the intersection of U. S. 21 and S. R. 1331. The site is located
in the northwest corner of the intersection of U. S. 21 and S. R. 1331.
6. The bearing and distance to the proposed point of effluent discharge
is: N/A. The co-ordinates of the point of discharge are as follows:
N 35044'45" and W 80053'40".
7. Size: Adequate for the continued operation of the wastewater treatment
facility.
3. Topography: Sloping at a rate of 5 to 10%. Site has been terraced
so slope is not severe.
9. Location of Nearest !,selling: Several within 1000 feet of the site.
10. Receiving Stream: Unnamed tributary to Third Creek.
(a) Classification: "C"
(b) Minimum 7-Day, 10-Year discharge at site: 0.3 cfs.
c) Usage: Fishing, boating, wading and any other best usage except
for bathing or as a source of water supply for drinking, culinary,
or food processing purposes.
Part II - DESCRIPTION OF TREATMENT WORKS
The wastewater generated on site is treated_in a system consisting of two
septic tanks having a combined capacity ofl'800Q:�GPD and dual surface
sand filters with a total surface area of 3200 feet square. The effluent
w J1_`b. disinfected by chlorination.prior to discharge into an unnamed
tributary to Third Creek,
The Nursing Home contains 107 beds at 150 gallons per bed. The total
wastewater generated should not exceed 16,050 gallons per day.

Page Two
Part III - EVALUATION AND RECOMMENDATIONS
The final effluent limitations promulgated by Technical Services for this
discharge at Hill Haven Nursing Home are as follows:
Parameter Monthly Average
BOD, 5=':Day, 200C 30 mg/l
TSS 30 mg/l
PH 6-9 s.u.
Fecal Coliform (Geometric Mean) 1000/100 ml
Samples collected June 20, 1980 produced the following laboratory data:
Parameter Results
BOB, 5-Day, 200C 4 mg/1
TSS 6 mg/l
PH 6.6 s.u.
Monthly self -monitoring data is not being submitted. It is felt that the
facility will be capable of meeting all the final effluent limitations
except for Fecal Coli€orm.
It is recommended an NPDES Permit be issued for the discharger. A
Special Order by Consent will be drafted to allow for construction of
disinfection facilities.

TROUTMAN QUADRANOLE
NORTH CAROLINA
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NQRTH CAROLINA DEPT.-OF NATURAL RESOURCES AND COMMUNITY DEVELOPMENT
ENVIRONMENTAL MANAGEMENT COMMISSION
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
'APPLICATION FOR PERMIT TO DISCHARGE - SHORT FORM D FOR
To be filhd only by services, wholesale and retail trade,
and other commercial establishments including vessels
AGENCY
USE
APPLICATION NUMBER
ear
W61�
DATE RECEIVED
d j,
1V. C.
RE$ it,QQ 1
AD CESA DAY
COMMUNITY DEVELOPMENT,,
Do not attempt to complete this form without reading the accompanying instructions MAY 2 LOBO
print or type
1. Name, address, and telephonlel numbers of facility producing discharge DIVISION OF ENVIRONMEATfIL lOAIJAGEMEti�1
/7 A Name /7 i/ deAJ 1�/L(/�-5�'i�o / vv E VnBRFRV111r nrp_muei nrrinr
B. Street address
C. City SfR fesUi /%
E. County � e- de-
G.
Telephone No.
Area
Code
2. SIC
0
60
D. State
F. ZIP Q 9b I%
a� �S �1� 76�0�.
eave a
3. Number of employees �3 �2
4. Nature of business --
5. (a) Check here if discharge occurs all year 0 ; or
(b) Check the month(s) discharge occurs: '
1. 0 January 2. O February 3. 0 March 4.0 Apri 1 5.13 May
6.0 June 7. 0 July 8. 0 August 9.0 September 10. o October
11.0 November. 12.0 December
(c) How many days per week:
1.01 2. 0 2-3 3.0 4-5 4.,46-7
6. Types of waste water discharged to surface waters only (check as applicable)
Flow, gallons per operating day
Volume treated before
discharging (percent)
Discharge per
operating day
0.1-999
1000-4999
5000-9999
10,000-
50,000
None
0.1-
30-
-65-
95-
49,999
or more
29.9
64.9
94.9
100
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(B)
(9)
(10)
A. Sanitary, daily
/
average
B. Cooling water, etc.,
daily average
C. Other discharge(s),
daily average;
Specify
D. Maximum per operat-
ing day for combined
discharge (all types)

7. If any of,the types of waste identified in item 6, either treated or un-
;treated.'are discharged to places other than surface waters, check below
as applicable.
Waste water is discharged to:
0.1-999
(1)
1000-4999
(2).
.5000-9999
(3)
10,000-49,999
(4)
50.000 or more
(5)
A. Munic.ipol xwur system
I�. Iln�lrryrnund wi•11
�.,
F. Sept.iv tank
U. Evaporation lagoon or pond
E. Other, specify:
B. Number of separate discharge points:
A. Xl B. 02-3 C.o 4-5 D.o 6 or more
9. Name of receiving water or waters
10. Does your discharge contain or is it possible for your discharge to contain
one or more of the following substances jLdas a result of your operations.
activities. or processes: ammonia. cyanide, aluminum, beryllium, cadmium.
chromium. copper. lead. mercur , nickel, selenium, zinc, phenols. oil and
grease, and chlorine (residual.
A.O yes D.A no
1 certify that 1 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.
Printed Name of Per on Signing
Ct I'll 1 N iS A-A,0 /b
Title
Date Applicatit Sig ed
li! u. A- R Cj 9 7
I- signature of Applicant
orth Carolina General Statute 143-21566(b)(2) provides that: Any person who knowingly makes
ny false statement representation, or'certification ;in.iany.application `record:, 'report'', plan,
r'other document files or required to be maintained under Article 21"or regulations of the
nvironmental Management Commission implemQnting that Article, or who falsifies, tampers with,
r'knowly renders inaccurate any ;ecoxding or monitoring device or method required to be
p,erated or maintained under Article 21 or -regulations of the Environmental Management Commissior
m1plemen�tYng-that Article, shall be"gutltv-of a misdemeanor punishable by a fine not.to exceed
0,000, or by imprisonment not 'to exceed six months, or by both. (18 iT.S.C. Section 1001 provide
punishment by a fine of"not more than $10,000 or imprisonment not more than 5 years, or tenth,
or a similar offense.)

COUNTY
RIVER BASIN
REPORT TO: (Circle One)
ARO, WSRO,`MRO, FRO, WaRO, WiRO, RRO, TS, BM
AM, OTHER
COLLECTOR
BOD RANGE SEED
CHLORINATED
Station No. Date Begin Time Begin
N. C. DEPT. OF NATURAL RESOURCES & COMMUNITY DEVELOPMENT
LAB NUMBERS
DIVISION OF ENVIRONMENTAL MANAGEMENT
f
DATE RECEIVED �•
FIELD/LAB FORM
a .
RECEIVED BY
WATER AMBIENT � CORE
DATA ENTRY By k CK_
-
SEDIMENT � COMPLIANCE SPLIT
❑ ❑
DATE. REPORTED
QTISSUE a INTENSIVE S. F-1 EMERGENCY
STATION LOCATION
REMARKS
Date End
Time End
Depth DM DB DMB
Value Type
T, S, or B
Sample Type
_
A
H L
C ° 'd - GNXX
I
COD ' { 1 mg/1
n n
Chloride 940 m /l
NH as N o m 1
Mn - Man anesetoas 1
COD m /.1
Arsenic toot u 1
* 62a
u
1062 u 1
Coliform, MF Fecal /100ml
Chl a Tri 32210 us/1
NO +NO as N 630 MR/1
Na - Sodium 929 mg/l
I
Coliform, MF Total 4 /100ml
Chl a Corr 32211 u /1
PO4 as P 705MR/1
Ni - Nickel 1067 u /l
i
Coliform Tube Fecal /1O0ml
Pheo h tin a 32218 u /1
P Total as P 665 mg/1
Pb - Lead to 1 u /1
Coliform, Tube Total.,,!,,,/100ml
Color (True) so units
A-'Silver1077 u /l
Sb - Antimony jp97 ug/l
Residue Total m 1
1032
Chromium Hexavajent u 1.
Al - Aluminum ttoa u 1
Sn - Tin 1102 ug/l
I
Volatile aos m l
-Cyanide
720 m l
Ba - Barium too
10u 1
Fixed 510 m /l
Flouride 9e1 MR/1
Be - Beryllium 1012 u 1
Zn - Zinc 1092 ug/1
Residue Suspended 530 ��: m /l
Formaldeh de 71e80 m /l
Ca - Calcium o16 mg/1
Pesticides (Specify)
Volatile 535 MR/1
Grease and Oils 5a6 mg/1
Cd - Cadmium 1027 u /l
Fixed 540 mg/1
Hardness Total goo MR/1
Co - Cobalt 1037 u 1
H units
MEAS 38260 MR/1
lChromium
- Total 1074 u /1
lOrganics
(Specify)
Acidity to pH 4.5 m /1
Phenols 32730 up/1
Cu - CODDerIO42 u 1
Acidity to pH 8.3 mg/1
Sulfate 945 m /l
Fe - Iron 1045 u /1
Alkalinity to pH 8.3 m /l
Sulfide 745 mg/1
H - MercurY 71900 u 1
A kalinity to PH 4.5 MFY1
Specific Cond 95 UMHOS cm
Li - Lithium 1132 u /1
Samplinp
TOC 660 mg/1
Point Tpmn_ ro
IM9
- Magnesium 927 mg/l
FT CY
A 63 4 10
Secchi Disk M
B 7a' 150
Stream Flow
Severity
C 13 1 132
- - 1 y.. v..uo
1 Hr. Set. Solids I Coonndductivity I Salinity S/L
Cloud Cover Precipitation
Inches
4a
Odor-Atmos Deter ent Suds
Severity Severity
D1330 11305
' DMI/REV. 9-78 - -
Dead Fish
Severity
1340
Pn o.J ALKa.Limity pn 4.3
la 1410
R.P. I Stream -Stage
Ft.
Wind Direction Wind Force
From North I Beaufort
Stream Color
pH 4.5 Acidity pH 8.3 (Turbidity Hach FTU
Flow, Inst. 172034
Hydro Elec.
CFS Dam Dis. CFS
Turbidity Oil -Grease I Sludge
Severity Severity Severity
11350 1300
Silt or Sediment I Identity
Susp. Severity Sed. Severity
Flow, MGD
Floating Debris
Severity
Aquatic Vegetatio
Suppert Medium Severy.
ty

4
5
6
8
9
I
' T1
12
1
1.4
1
1
1
18
COUNTY
N. C. DEPT. OF NATURAL
RESOURCES & COMMUNITY DEVELOPMENT
LAB NUMBERS
RIVER BASIN
DIVISION OF
ENVIRONMENTAL MANAGEMENT
DATE RECEIVED
FIELD/LAB FORM
REPORT TO: (Circle One
RECEIVED By
ARO, WSRO, FRO,
WaRO, WiRO, RRO,
TS, BM
-
f��=
�•
+MRO;)
WATER
AMBIENT CORE
DATA ENTRY BY
CK
C
F
AM, OTHER
y
❑ SEDIMENT
COMPLIANCE
❑
SPLIT
DATE REPORTED
COLLECTOR
TISSUE
INTENSIVE S.
Q
EMERGENCY
BOD RANGE
SEED
STATION LOCATION
s L.1
CHLORINATED "�,+
REMARKS
i -'• . r 1
Station No.
Date Begin
Time
Begin
Date End
Time End
Depth DM DB DNB
Value Type
T, S, or B
Sample Type
A H L
C
f;Gt GNRX
3
5
8
7lAlkalinity
✓
BOD E mg/l
Chloride 940 mg/1
`
NH as N m 1
Mn - Man anese1055 u 1
COD m 1
Arsenic 1002 u 1
T 62s
- 1062 u 1
Coliform, MF Fecal /100ml
Chl a Tri 32210 u /l.
NO +NO as N e3o mg/1
Na - Sodium 929 nag/1
Coliform, MF Tota13 4 /100ml
Chl a Corr. 32211 u /1
PO as P 705m 1
Ni - Nickel 10e7 u /7
Coliform Tube Fecal /lOOml
Pheo h tin a 32218 a/1
P Total as P to 1
Pb - Lead to t ug/1
Coliform, Tube Tota131 /100ml
Color (True) go units
A - Silver1077 u /1
Sb - Antimony1 ug/1
Residue Total m 1
f032
Chromium Hexavalent u. 1.
Al - Aluminum 1105 u 1
Sn - Tin 1102 ug/l
Volatile 5os m 1
Cyanide 720 m 1
Ba - Barium tool
- I... u 1
Fixed 510 m /l
Flouride 951 m 1
Be - Beryllium 1012 u 1
Zn - Zinc 1092 ug/1
Residue Suspended 530 S mg/1
Formaldeh de 7188o mg/1
Ca - Calcium 9t6 m 1
Pesticides (Specify)
Volatile 535 m 1
Grease and Oils 556 m 1
Cd - Cadmium 1027 u /1
Fixed 54 MR/1
Hardness Total 900 MR/1
Co - Cobalt 1037 u 1
H 403 /J �__- units
MEAS 3 0 mg/1
Chromium - Total 10-44 u 1
Or anics (Specify)
Acidityto H 4.5 mg/1
Phenols 32730 u 1
Cu - Co er1042 u. 1
Acidityto H 8.3 mg/1
Sulfate 945 mg/1
Fe - Iron 1045 u /1
Alkalinityto H 8.3 mg/1
Sulfide 745 m /l.
H - Mercur 7190o u 1
Alkalinityto PH 4.5 m 1
S ecific Cond 9s UMHOS cm
1.
Li - Lithium 1132 u /1
1Mg
TOC eeo m /1
- Magnesium 927 mg/1
Sampling Point Temp. Co D.O. pH Units pH 8.3 Alkalinity ph 4.5 1 pH 4.5 Acidity pH 8.3 [Turbidity Hach FTU
P
I900
I400
1415
ii 63
10
`!' . /"
.,Secchi Disk M
1 Hr. Set. Solids
Cddgctivity
Salinity S/L
R.P.
I50086
UNHO
I
I
181647
B 78
195
170305
-Stream Flow Cloud Cover
Preci.pi.tation
Wind Direction
Wind Force
,,SeverityI
Inches
145
From North
136
Beaufort
137
C t351
32
Stream-Stage161
Flow, In.st. 1Dydro HElec. Flow, MGD
Ft. CFS am Dis. CPS
72034 150051
Turbidity I Oil -Grease I Sludge I Floating Debris
Sever it Severit Severity Severity
,Odor-Atmos Deter ent Suds Dead Fish Stream Color Silt or Sediment
'Severity Severity Severity Susp. Severity Sed. Severity
D 1330 11305 I1340 I l
- DMl/REV. 9-78
Identity I Aqguatic Vegetatio
Suppert Piedium Severity

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
COUNTY OF
IN THE MATTER OF )
NORTH CAROLINA )
NPDES PERMIT NO. ) SPECIAL ORDER
NC0045012, HELD ) BY CONSENT
BY HILL HAVEN NURSING HOME ) EMC WQ NO.
Pursuant to provisions of North Carolina General Statute 143-215.2, this
SPECIAL ORDER. BY CONSENT is made and entered into by Hill Haven Nursing Home,
hereafter referred to as the Home, and the North Carolina Environmental -
Management Commission, an agency of the State of North Carolina created by
North Carolina -General Statute 143B-282, and hereafter referred to as the.
Commission:
1. The Home and the Commission hereby stipulate the following facts:
(a) That the Home holds North Carolina NPDES Permit No. NC 0045012,
making an outlet to an unnamed tributary to Third Creek, waters
of this State;
(b) That the Home is unable to comply with the Fecal Coliform
limitation in Part I. A.(1) of the Permit, without constructing
and properly operating disinfection facilities and continuing
to properly operate and maintain the existing wastewater treatment
facility;
(c) That non-compliance with the conditions of the Permit identified
in paragraph l(b) above constitutes causing/contributing to
pollution of waters of this State named above;
(d) That the Home is within the jurisdiction of the Commission as-
set forth in -Chapter 143, Article 21 of the North Carolina
General Statutes;
(e) That the Home hereby waives its right to a hearing on the terms
of this Special Order by Consent pursuant to procedural require-
ments of North Carolina General Statute 143-215.4 and Commission
rules in 15 NCAC, 2I, and also hereby waives its right to appeal
this Special Order by Consent in accordance with North Carolina
General Statute 143-215.5.
2. The Home, desiring to comply with conditions of the Permit identified
in paragraph l(b) above, does hereby agree to do and perform all of the
following things:
(a) Comply with all conditions of the Permit except those identified
in paragraph l(b) above;

Page Two
4
(b) Upon execution of this Order, undertake the following activities
in accordance with the indicated time schedule:
1. Submit plans and specifications on or before December 1, 1980.
2. Begin construction on or before March 31, 1981.
.3. Complete construction and comply with final limits on or before
June 30, 1981.
(c) During the time in which this Special.Order by Consent is effective,
comply with the following interim effluent limitations:
Parameter Monthly Average
BOD, 5-Day, 200C 30 mg/l
TSS 30 mg/1
pH 6-9 s.u.
Fecal Coliform (Geometric Mean) 1000/100 ml
(d) No later than 14 calendar days after any date or time identified
for accomplishment of any activity listed in 2(b) above, submit
to the Director, Division of Environmental Management, North
Carolina Department of Natural Resources and Community Develop"
ment, written notice of compliance or non-compliance herewith.
In the case.of non-compliance, the notice shall include a state-
ment of the reason(s) for non-compliance, remedial action(s)
taken, and a statement identifying the extent to which subsequent
dates or times for accomplishment of listed activities may be
affected.
3. Any violation of .terms of this Special Order by Consent, including
failure to achieve interim effluent limitations set forth at para-
graph 2(c)-above, subject the Home to enforcement authority of the
Commission and of the Director pursuant to North Carolina General
Statute 143-215.6 and Commission rules in 15 NCAC 2J.
4. This Special Order by Consent shall expire on June 30, 1981,
Entered into this the day of
Hill Haven Nursing Home
By: 19 T
North Carolina Environmental Management Commission
by 19_
Chairman of the Commission

�t4 North Carolina Department of Natural
- Resources &Community Development
� 1 James B. Hunt, Jr., Governor Joseph W. Grimsley, Secretary
v August 26, 1983-
DIVISION OF
ENVIRONMENTAL
MANAGEMENT
Robert F. Helms
Director
Telephone [phone] -
Ms. Dorothy S. dwards, Administr or
Hill Haven Nursing Home AUG
Route 10, Box 401 19&3
Statesville, North Carolina 28577.
SUBJECT: Permit No. NCO045012
Hill Haven Nursing Home
Iredell Coy -t;
Dear Ms. Edwards:
The Mooresville Regional Office has conducted a field investigation in.
response to your request to have the influent sampling in the subject NPDES
Permit removed. It has been determined that influent samples would.be
neither practical nor informative. For these reasons, the sampling -location
requirements are being revised to eliminate the influent sampling: Attached
is a revised effluent limitations page which should be included in your-NPDES
Permit.
If you have any questions concerning this modification, please contact
Mr. David T. Adkins, telephone.[phone].
Or gin�(rsiAeWs
fORREST R. WESTALL
FOR
Robert F. Helms
Director
cc: Mr. Jim Patrick, EPA
Rrex G^���a
Mooresville Regional Manager
POLL UTION PREVENTION PA YS
P. 0. Box 27687 Raleigh, N. C. 27611-7687
An Equal Opportunity Afflrmative Actlon Employer

A. (1). EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS Final
During the period beginning on the effective date and
lasting Until expiration,
001.
the permi ttee is authori zed';tlla. discharge. from -,ou.tfal-1 (s) serial
numbers) .
below:
Such discharges- shall be -l.iMited and monitored by the permittee
as .specified
Effluent Characteristics Discharq(a Limitations
Monitoring
Requirements
K da lbs/da Other -Units (Specify)
Measurement
Sample
Sample
.Monthly. Av Weevg..Mont y vg.- ee y... vg..
. • ; ; requency -;_ :
,; Type
Location
Flow 0:018 MGD
Weekly Instantaneous
E
�. �..
30 mg . 45 mg/1•'.
Semi -Annually
Grab..
E,U,D
BODS.
BOD 30 mg/1 45 mg/l
Annually
GrabTSS
E
1000/100 ml 2000/100 ml
Semi -Annually
Grab
E,U,D
Fecal Conform.
.....
Quarterly-
EU.�D..... .
pH;Grab:.
Monthly
Grab:
E,U,D
Dissolved Oxygen'
Monthly .. _ ..
Grab
E
Settleable Matter.
Monthly.,
Grab
E
Residual Chlorine
R
Semi -Annually
Grab
E,U,D
COD
Annually
Grab
E
Nei . as �T
3
Annually
Grab.,
E
Total Residue '
•
Monthly
Grab ..
E,U,D.:
Temperature:
* Sample Loactions: E - Effluent,.U.•- Upstream, D - Downstream
The -temperature of.the -°effluent shall be such that it will not cause an increase in the temperature of the
cause the stream temperature
receiving
to
stream of more than 2.8 C above ambient st?eam'water.temperature.and in no case
exceed .320C.
c�m�a
,. _ ..
N• O f�D cam+
The .pH shall not be less tharr. 6.o standard units nor greater
than 9.0 .,standard
units.
a � �+
- There shall be no discharge a:i floating solids or visible foam
in other than trace amounts.
CO oz
N N o
\
co

DIVISION OF ENVIRONMENTAL MANAGEMENT
April 7, 1983
MEMORANDUM TO: -Forrest Westal1 G
FROM: D. Rex Gleason
PREPARED BY: Larry D., Coble t—
SUBJECT: Amendment to Permit No. NC 0045012
Hill Haven Nursing Home
I'redell County, North Carolina
Attached is a letter dated March 31, 1983 from Mr. Homer P. Edwards,
owner of Hill Haven Nursing Home. The letter requests that the subject Permit
be amended to delete influent monitoring requirements.
The subject Permit was issued January 13, 1981 for the continued operation
of an existing 18,000 gpd wastewater treatment system consisting of dual
septic tanks, dual sand filter and effluent disinfection facilities.
Investigations by the Mooresville Regional Office staff have found that
there is no provision made for influent sampling on the existing facility.
It is also the staffs opinion that influent samples would show little variation
over time and are not necessary for the proper operation of the facility.
Therefore, it is recommended that the Permit be amended to delete influent
monitoring as requested.
If you have any questions, please advise.
Attachment
cc: Dave Adkins

y.
,isJ
\ +
11.`ItF
n
J
I-I;1;LL;rdAVN;S,.iED NURSING HOME AND REST HOME
ROUTE 10, BOX 401
"'`'t%ST�4TFS/�hLLE, NORTH CAROLINA 28677
;_; G: � ``}} PHONE [phone] OR 872-7602
e t' � 4
.
njt �`Sm�IU
march 31, 1983
.s
Mr. D• Rex GZeas`on, P. 'E.
Division 0f Environmental Management
N• C• Department of Natural Resources
And Community Development
919 North main Street
Mooresville, N. C. 28115-0950
Dear Mr. Gleason,
In reference to your letter dated March 25, 1983 of Compliance Eval-
uation Analysis, I would like to give you the following report.
Due to our system, we have no provisions to get influent samples.
We would like to ask for a variance on influent monitoring require-
ments if possible or could this be deleted?
Sincerely,
Homer P. Edwards
HPE/e,j

R E�kpif. OF
'Soi u "9
UlStON° OF Ea„t�thi� �1�d
'Itgal ION OF ENVIROMTINTAL Ift�1AG3'�IENT
April14, 1981
�U tir.. Rosner Edwards
0� Hill Haven Nursing Hone. Inc.
Route 10, Box'401
Statesville, North Carolina 29677
Subject: Special Order by Consent
U hill Haven Nursing Home, Inc.
Iredell County, NC
Dear ter. Edwards
The Environmental TMianagement Commission in session on April9; 19813
approved and executed the attached Consent Order. The terms and conditions
of the Consent Order are in -full effect. You are reminded that the final
limits contained in the permit will not ;be enforced. by the State of North
Carolina provided bill Haven complies with the -limits, schedules and condi-
tions contained' in' the Consent Order.
Sincerely yours,
Original Sic;tood By
ROBERT F. HELMS
Robert �* . Hellas
Director
kU4/cJ
cc: Enforcement & Emergency Responses
-Ioa resville. Pe- ionAl Of € ice L11-11
office of Le;nl MfairG
Howard Zeller, EPA

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
COUNTY OF WAKE
IN THE MATTER OF )
NORTH CAROLINA )
NPDES PERMIT NO. ) SPECIAL ORDER
NC0045012, HELD ) BY CONSENT
BY HILL HAVEN NURSING HOME ) EMC WQ NO. 80-32
Pursuant to provisions of North Carolina General Statute 143-215.2, this
SPECIAL ORDER BY CONSENT is made and entered into by Hill Haven Nursing Home,
hereafter referred to as the Home, and the North Carolina Environmental
Management Commission, an agency of the State of North Carolina created by
North Carolina General Statute 143B-282, and hereafter referred to as the
Commission:
1. The Home and the Commission hereby stipulate the following facts:
(a) That the Home holds North Carolina NPDES Permit No. NC 0045012,
making an outlet to an unnamed tributary to Third Creek, waters
of this State;
(b) That the Home is unable to comply with the Fecal Coliform
limitation in Part I. A.(1) of the Permit, without constructing
and properly operating disinfection facilities and continuing
to properly operate and maintain the existing wastewater treatment
facility;
(c) That non-compliance with the conditions of the Permit identified
in paragraph l(b) above constitutes causing/contributing to
pollution of waters of this State named above;
(d) That the Home is within the jurisdiction of the Commission as
set forth in Chapter 143, Article 21 of the North Carolina
General Statutes;
(e) That the Home hereby waives its right to a hearing on the terms
of this Special Order by Consent pursuant to procedural require-
ments of North Carolina General Statute 143-215.4 and Commission
rules in 15 NCAC, 21, and also hereby waives its right to appeal
this Special Order by Consent in accordance with North Carolina
General Statute 143-215.5.
2. The Home, desiring to comply with conditions of the Permit identified
in paragraph l(b) above, does hereby agree to do and perform all of the
following things:
(a) Comply with all conditions of the Permit except those identified
in paragraph l(b) above;

Page Two
(b) Upon execution of this Order, undertake the following activities
in accordance with the indicated time schedule:
1. Submit plans and specifications on or before April 15, 1981.
2. Begin construction on or before May 15, 1981.
3. Complete construction and comply with the fecal coliform
effluent limitation at Part IA1 on or before July 1, 1981.
(c) During the time in which this Special Order by Consent is effective,
comply with the following interim effluent limitations:
Pirnmotor
BOD, 5-Day, 20oC
TSS
pH
Monthly Average
30 mg/l
30 mg/1
6-9 s.u.
(d) No later than 14 calendar days after any date or time identified
for accomplishment of any activity listed in 2(b) above, submit
to the Director, Division of Environmental Management, North
Carolina Department of Natural Resources and Community Develop"
ment, written notice of compliance or non-compliance herewith.
In the case of non-compliance, the notice shall include a state-
ment of the reason(s) for non-compliance, remedial action(s)
taken, and a statement identifying the extent to which subsequent
dates or times for accomplishment of listed activities may be
affected.
3. Any violation of terms of this Special Order by Consent, including
failure to achieve interim effluent limitations set forth at para-
graph 2(c) above, subject the Home to enforcement authority of the
Commission and of the Director pursuant to North Carolina General
Statute 143-215.6 and Commission rules in 15 NCAC 2J.
4. This Special Order by Consent shall expire on June 30, 1981.
Entered into this the day of
Hill Haven Nursing Home
North Ca Xua nvironm ntaY�. nt Commission
by:
n oV the Commissi

RECEIVED
'DIVISION OF °JlrFlrr;; QUALITY
Azc
APR -2 3 2014
F
'
NCDENRNiOORE �JsLLE E-GiONIAIOFFIC.E
North Carolina Department of Environment and Natural Resources
Pat McCrory John E. Skvarla III
Governor Secretary
April 15, 2014
Sent via Certfied Mail — Item 7010 2780 0003 4825 6410
Ms. Pamela Ford
Hill Haven Residential Care
142 Oak Haven Rd
Statesville, NC 28625
Subject: Expiration of NPDES Permit NC0045012
Hill Haven Residential Care WWTP
Iredell County
Dear Ms. Ford:
This letter is to formally notify you that your NPDES wastewater discharge permit for the subject
facility expired on March 31, 2014. Any wastewater discharge from this facility is illegal without a
valid NPDES permit.
Please note that NC0045012, the previous permit, cannot be renewed. By allowing your existing
permit to expire, you are now required to apply for a new NPDES discharge permit before any wastewater
discharge can occur. We realize that further discharge from your facility is unlikely, given that it last
discharged in 2006.
If you have any questions concerning this matter, or if you wish to obtain the application materials
for a new NPDES permit, please contact Charles H. Weaver at [phone] or via e-mail
[charle s. we aver@nc denr. gov] .
P
ely,
s A. Reeder, Dor
Division of Water Resources
cc: Central Files
1Vlooresville RegionV d L'Marci`a.Allocco
—NPDES Unit
1617 Mail Service Center, Raleigh, North Carolina 27699-1617 512 North Salisbury Street, Raleigh, North Carolina 27604
Phone: [phone] / FAX [phone] / Internet: www.ncwaterquality.org
An Equal Opportunity/Affirmative Action Employer — 501/6 Recycled/101/6 Post Consumer Paper

RCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Resources
PatMcCro Thomas A. Reeder O���t��oht�Sl�v�arla III
ry Dt�rtstoty OF V_V ct �_ r
Governor Director Secretary
September 5, 2013
SEP 24 20113
£ 1�P SSCTtPGN
Pamela Ford
MOORESVILLE REGIONAL OFFICE
Hill Haven Residential Care
142 Oak Haven Rd
Statesville, NC 28625
Subject: Renewal Notice
NPDES Permit NCO045012
Hill Haven Residential Care
Iredell County
Dear Permittee:
Your NPDES permit expires on March 31, 2014. Federal (40 CFR 122.41) and
North Carolina (15A NCAC 2H.0105 (e)) regulations state that permit renewal
applications must be filed at least 180 days prior to expiration of the current
permit. If you have already mailed your renewal application, you may disregard this
notice.
Your renewal package must be sent to the Division postmarked no later than
October 2, 2013. If any wastewater discharge will occur after March 31, 2014, the
current permit must be renewed.. Failure to submit a renewal application by the
deadline would deny the subject facility the automatic permit extension granted by
NCGS 150B.
If all wastewater discharge has ceased at your facility and you wish to
rescind this permit, contact me at the telephone number or address listed below.
Use the enclosed checklist to complete your renewal package. The checklist
identifies the items you must submit with the permit renewal application. If you
have any questions, please contact me at the telephone number or e-mail address
listed below.
Sincerely,
Charles H. Weaver, Jr.
NPDES Unit
cc: Central Files
Moores�r� lle Regional 'Offices'`Surf ace Water�Protection
NPDES ^File
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
512 North Salisbury Street, Raleigh, North Carolina 27604
Phone: [phone] / FAX [phone] / [e-mail]
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper

NPDES Permit NCO045012
Hill Haven Residential Care
Iredell County
The following items are REQUIRED for all renewal packages:
➢ A cover letter requesting renewal of the permit and documenting any
changes at the facility since issuance of the last permit. Submit
one signed original and two copies.
➢ The completed application form (copy attached), signed by the
permittee or an Authorized Representative. Submit one signed
original and two copies.
➢ If an Authorized Representative (such as a consulting engineer or
environmental consultant) prepares the renewal package, written
documentation must be provided showing the authority delegated to
any such Authorized Representative (see Part II.B.11.b of the
existing NPDES permit).
➢ A narrative description
facility. Describe how
wastewater treatment are
has no such plan (or the
solids), explain this in
two copies:
of the sludge management plan for the
sludge (or other solids) generated during
handled and disposed. If your facility
permitted facility does not generate any
writing. Submit one signed original and
The following items must be submitted by any Municipal or
Industrial.facilities discharging process wastewater:
Industrial facilities classified as Primary Industries (see Appendices
A-D to Title 40 of the Code of Federal Regulations, Part 122) and ALL
Municipal facilities with a permitted flow >! 1.0 MGD must submit a
Priority Pollutant Analysis (PPA) in.accordance with 40 CFR Part
122.21.
The above requirement does NOT apply to privately owned
facilities treating 100% domestic wastewater, or facilities
which discharge non -process wastewater (cooling water,
filter backwash, etc.)
Send the completed renewal package to:
Charles H. Weaver
NC DENR / DWR / NPDES Program
1617 Mail Service Center
Raleigh, NC 27699-1617
t

c
RE CE IV ED
NCDENR DEC 4 3
Division of Water Quality
1618 Mail Service Center
Raleigh NC 27699 - 1618
Subject: Hill Haven Residential Care, Inc. NC, permit # NCO045012
To Whom it May Concern,
It has come to my attention that there is no letter on file concerning the cessation of
operations for the above mentioned facility. As of November 8, 2006, neither Statesville Analytical,
Inc. nor any of its employees are involved in the operations of the WWTP mentioned above. The
facility closed the doors and our services ended on November 8, 2006. Please see enclosed letter from
the tenant at the above mentioned facility.
Prior to November 8, 2006, the Following Statesville Analytical, Inc. employees were operating
the WWTP:
Jerry Rogers Cert # 7752, ORC
Dena Myers Cert # 993409, Back up
Harry Myers Cert # 987023, Back up
Please remove the above names as a contact concerning permit number NC0045012.
If you have questions or need further information please contact me at 704-872-4697.
Sincerely,
av'A-Aoly
Dena Myers, Statesville Analytical, Inc.
1
P.O. Box 228 •. Statesville, North Carolina 28687 . 7041872/4697

The signatures below serve as agreement to remove their name from operational d
associated with NC0045012.
Jerry Rogers //, /Z,� �17 Z,
IV -
Dena Myers a �" '� `-� r
Z�Harry Myers
2
P.O. Box 228 9 Statesville, North Carolina 28687.704/872/4697

�; -�- .I� . tl:�'�:ItIs1Ic3ItI�• • � . . �i�.Ti�-.�lilfi - . �
NOV 08,2006 15:05 7048710451 Page 2
tO
November 8, 2006
To Whom It May Concern:
Please allow this letter to serve as official notification that etlective November 30,2006.
the Ark ol'Refuge will be closing its facility located at:
114 Hill Haven Road
Statesville, NC 28677
We arc requesting that services at this lovation he terminated on this date.
Please feel free to contact our office at 704-878-3950 should you have any questions.
Sincerely, )
7 ;Aft
Mary ` J. T� fo
y r
Executive Director
I 1 1 lull Ilarci� Kn;ul Suilczvill�, tiv1'�11 �.;u'g1i11:� -'f+77 'rc1:-0-1-ti7Y-3950 I ax: ?u4.,(71-1i15!

A,
NCDENR - -
North Carolina Department of Environment and Natural
Division of Water Quality
Beverly Eaves Perdue, Governor ee„r�rran,.S�ec eta
NCoI en H.`Su Iins,�Di ec orr
January 14, 2009
Ms. Pamela E. Ford
Hill Haven Residential Care
224 Augusta Drive .
Statesville, N.C. 28625
Resources
JA N 16 2009
M-Surface Water Pfoledion
Subject: Draft NPDES Permit NCO045012
Hill Haven Residential Care WWTP
Iredell County
Dear Ms. Ford:
The Division has reviewed your request to renew the subject permit. Please review this draft
permit carefully to ensure your thorough understanding of the information, conditions, and
requirements it contains.
The draft permit includes the following significant changes from the existing permit:
➢ A new Total Residual Chlorine (TRC) compliance level of 50 µg/L has been added. See
section A. (1) for details.
➢ A facility certification condition has been added. Due to the poor condition of the WWTP
since it ceased discharging, all components must be inspected and certified by a
Professional Engineer prior to any future discharge [see A. (2) for details].
Please be aware that Third Creek is listed as an impaired stream on North Carolina's � 3 03(d) list.
This means that the stream does not meet all water quality. standards. The Division is working
toward the improvement of water quality in Third Creek. If the current changes to permits
discharging to Third Creek do not result in improved water quality, removal of discharges to Third
Creek may. be necessary for the health of the stream.
Although the Division believes non -point sources [including agricultural runoff] are the main
cause of degradation to Third Creek, we will continue to monitor compliance at your facility. If
noncompliance with your permit's effluent limits is shown to be a direct cause of stream
degradation, the Division will recommend removal of your facility's discharge. Part.III of your
permit requires you to "continually evaluate all wastewater disposal alternatives and pursue the
most environmentally sound alternative of the reasonably cost effective alternatives" to surface
water discharge. Such an evaluation may help you find an alternative to surface water discharge
that is more appropriate for your facility.
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
512 North Salisbury Street, Raleigh, North Carolina 27604
Phone: [phone] / FAX [phone] / Internet: www.ncwaterquality.org
An Equal Opportunity/Affirmative Action Employer — 50% Recycled/10% Post Consumer Paper
NorthCarohna
Nahmally

With this notification, the, Division will solicit public comment on this draft permit by publishing a
notice in newspapers having circulation in the general Iredell County area, per EPA requirements.
Please provide your comments, if any, to me no later than 30 days after receiving this
draft permit.
Following the 30-day public comment period, the Division will review all pertinent comments and
take appropriate action prior to issuing a final permit. If you have questions concerning the draft,
please call me at [phone], or you may e-mail me at [e-mail].
Sincerely,
Charles H. Weaver, Jr.
NPDES Unit
cc: Central Files
Mooresville:Regional-office / Doe Browder
NPDES Unit

Permit NCO045012
-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,
Hill Haven Residential Care, Inc.
is hereby authorized to discharge wastewater from a facility located at the
Hill Haven Residential Care
224 Augusta Drive
Statesville
Iredell County
to receiving waters designated as an unnamed tributary to Third Creek in subbasin 03-07-
06 of the Yadkin -Pee Dee River Basin in accordance with effluent limitations, monitoring
requirements, and other conditions set forth in Parts I, II, III, and IV hereof.
The permit shall become effective
This permit and the authorization to discharge shall expire at midnight on March 31, 2014.
Signed this day
Coleen H. Sullins, Director
Division ,of Water Quality
By Authority of the Environmental 'Management Commission.

Permit NCO045012
SUPPLEMENT TO PERMIT COVER SHEET
All previous NPDES Permits issued to this facility, whether for operation or discharge are hereby revoked. As of this
permit 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.
Hill Haven Residential Care, Inc. is hereby authorized -to:
1. Continue to operate an existing 0.018 MGD wastewater treatment plant
consisting of the following components:
Two septic tanks
Two surface sand filters
Effluent chlorination
The facility is located at Hill Haven Residential Care [224 Augusta Drive,
Statesville] in Iredell County..
2. Discharge from said treatment works at the location specified on the attached
map into an unnamed tributary to Third Creek, currently. classified C waters in
subbasin 03-07-06 of the Yadkin -Pee Dee River Basin.

V--
. V
1 f/0
Discharge location
Y!
N
A
L
V--
0930
.0
1
1V 'A 11
?
j
j
dh
fell
2 � i a
Zz - 5
V
P
7-
X
\X
".
-Z 7L—
j
-7
J
A
IN I
-7,
-21
Sill Haven Residential Care WWTP — NCO045012 Facility
USGS Quad Name: Troutman Lat.: 35'44'45" Location
Receiving Stream: UT to Third Creek Long.: 80'53'44"
Stream Class: C §ubbasin: 03-07-06 North - Not to SCALE11 1

Permit NCO045012
A. (1). EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS- -. -
During the period beginning after receipt of the Facility certification described in A. (2) 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
Monthly
Daily
Measurement
Sample
Sample
Average
Maximum
Frequency
Type
Location'
Flow
0.018 MGD
Weekly
Instantaneous
Effluent
BOD, 5 day, 20 2C
30.0 mg/L
45.0 mg/L
2/Month
Grab
Effluent
Total Suspended Solids,
30.0 mg/L.
45.0 mg/L
2/Month
Grab
Effluent
NH3 as N
(April 1 to October 31)
9.4'mg/L
35.0 mg/L
2/Month
Grab
Effluent
NH3 as N
30.0 mg/L
35.0 mg/L
2/Month
Grab
Effluent
(November 1 to March 31)
Fecal Coliform
200/100 mL
400/100 mL
2/Month
Grab
Effluent
(geometric mean)
-Total Residual Chlorine
28jig/L
2/Week
Grab
Effluent
(TRC)2
Temperature
Weekly
Grab
Effluent
Total Nitrogen
Quarterly
Grab
Effluent
NO2 + NO3 + TKN
Total Phosphorus
Quarterly
Grab
Effluent
pH
> 6.0 and < 9.0 standard units
2/Month
Grab
Effluent
Notes:
1. TRC limit and monitoring requirements apply ONLY if chlorine is used for disinfection. The facility
shall report all effluent TRC values reported by a NC certified laboratory including field certified.
However, effluent values below 50 µg/L will be treated as zero for compliance purposes.
There shall be no discharge of floating solids or foam visible in other than trace amounts.
A. (2) FACILITY CERTIFICATION REQUIREMENT
Due to the decline of the WWTP since the facility ceased discharging, all existing components
must be certified as operational prior to any future wastewater discharge.
➢ A Professional Engineer licensed in North Carolina must inspect and certify all facility
components. The record of the inspection and certification shall be provided to the NC
DENR Mooresville Regional Office (MRO) and the NPDES program.
➢ The MRO must review and approve the Facility Certification in writing prior to any future
wastewater discharge.
Send the Facility Certification to:
NC DENR / DWQ / NPDES Surface Water Protection
Western Program Supervisor and NC DENR / Mooresville Regional Office
1617 Mail Service Center 919 North Main St
Raleigh, NC 27699-1617 Mooresville, NC 28115

ACDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Michael F. Easley, Governor William G. Ross, Jr., Secretary
Coleen H. Sullins, Director
August 15, 2008
Pamela Ford RE
94�
Hill Haven Residential Care
224 Augusta Dr
Statesville, NC 28625
AUG 1 8 2008
Subject: Renewal Notice
NPDES Permit NC0045012 . ®ENR 1MR0
Hill Haven Residential C
Iredell County
. p���Surlace �Igter protection
Dear Permittee:
Your NPDES permit expires on March 31, 2009. Federal (40 CFR 122.41) and North Carolina (15A
NCAC 2H.0105 (e)) regulations state that permit renewal applications must be filed at least 180 days prior
to expiration of the current permit. If you have already mailed your renewal application, you may
disregard this notice.
Your renewal package must be sent to the Division postmarked no later than October 2, 2008..
Failure to request.renewal by this date may result in.a civil penalty assessment.. Larger penalties may be
assessed depending upon the delinquency of the request.
If any wastewater discharge will occur after March 31, 2009, the current permit must be renewed.
Discharge of wastewater without a valid permit would. violate North. Carolina General Statute ,143-215.1;
unpermitted discharges of wastewater may be assessed civil penalties of up to $25,000 per day.
If all wastewater discharge has ceased at your facility and you wish to rescind this permit,. contact
me at the telephone number or address listed below:
Use the enclosed checklist to complete your renewal package. The checklist identifies. the items you
must submit.with the permit renewal application. If you have any questions, please contact meat the
telephone number or e-mail address listed below.
Sincerely,
t`"""/
l
Charles U. Weaver, Jr.
NPDES Unit
cc: Central Files .
ooresville Re oUna l Office Surface Water Protectio
NPDES File
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
512 North Salisbury Street, Raleigh, North Carolina 27604
Phone: [phone] / FAX [phone] / [e-mail]
An Equal Opportunity/Affirmative Action Employer - 50% Recycled/10% Post Consumer Paper
One
NortlCarolina
Naturally

NPDES PERMIT NC0045012
HILL HAVEN RESIDENTIAL ,CARE
IREDELL : COUNTY
The following items are .REQUIRED for all renewalpackages:
➢ . A cover :letter requesting renewal of the permit and documenting any changes at the facility since
issuance of the last permit. Submit one signed original and two copies.
➢ . The completed application forme (copy attached), signed by the permittee or an Authorized
Representative. Submit one signed original and two copies.
➢ If an Authorized Representative (such as a consulting engineer or environmental consultant) prepares
the renewal package, written documentation must be provided showing the authority delegated to .any
such Authorized Representative (see Part II.B.11.b.of the existing NPDES permit).
➢ A narrative description of the sludge managementplan for. the facility. Describe how sludge (or other
solids) generated during wastewater treatment are handled and disposed. If your facility has no such
plan (or the permitted facility does not generate any solids), explain this in writing. Submit one signed
original and two copies,.,
The following items must be submitted by anv Municipal or Industrial. facilities dischar6nLy
process wastewater:
Industrial facilities classified as Primary Industries (see Appendices A-D to Title 40 of the Code of Federal
Regulations, Part 122) and ALL Municipal facilities with a permitted flow >_ 1.0 MGD must submit a
Priority Pollutant Analysis (PPA) in accordance with 40 CFR Part 122.21.
The above requirement does NOT.apply. to privately owned facilities treating 100%
domestic wastewater, ,or.faciU es which discharge non. -process wastewater (cooling
water, filter backwash, etc.)
Send the.completed renewal package to:
Mrs. Dina ' Sprinkle
NC DENR / DWQ / Point Source Branch
1617 Mail Service Center
Raleigh, NC 27699-1617

Y i N�6 HILL HAVEN RESIDENTIAL CARE, INC.
C/O Pamela Edwards Ford
224 Augusta Drive
Statesville, North Carolina 28625
� �lllllllllllllllll!/lllllllllllllllllllllllllllllllll!/llllllllllllllllllll/llllllflllllll///!lllllllllllllflllllllll/Illll
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��IjV A,M MA?URZAL RESOURCE$'
� '�9QOFd�SUiLG,C� :=���#O��L OFFICE
I r
NOV 1 5 200e
November 12, 2006
D. Rex Gleason
Surface Water Protection Regional Supervisor
NCDENR — Division of Water Quality
610 East Center Avenue
Mooresville, North Carolina 28115
Re: Hill Haven Residential Care, Inc.
NPDES Permit No. 0045012
Dear Mr. Gleason:
WATER OUALITY SECTICOY,
I am writing to notify,you that the Hill Haven building that has been occupied by
approximately 5-10 persons since September, 2005, will once again be vacant as of
November 30, 2006. There will be no occupancy and no influent flow into the treatment
plant; therefore, I am respectfully requesting that inactive status be granted to Hill Haven
as of December 1, 2006.
6 lease -note, for=y_our_records; the aliove address.change for Hi11-Haven:
Thank you for your assistance regarding these matters.
Sincerely,
Pamela Edwards Ford
President

.. rt C. .. .' it: � ..
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Postage
Certi led FeeReturnRecleptFeePo(EndorsementRequired)Restricted
$
jL/
DelreryFees3dC�(Endorsement Requlred)
4,
PAMELA EDWARDS FORD
sw. HILL HAVEN RESIDENTIAL. CARE
sir 224 AUGUSTA DRIVE -------------
bri STATESVILLE NC 28625
°'b WP
sJ
/ 1 4/25/06
�_

Certified Mail Provides: asianaal zoozeunr'oogEuuojg�
■ A mailing receipt
■ A unique identifier for your mailplece
■ A record of delivery kept by the Postal Service for two years
'mportant R nders.
■ Certified ga', jay.QNLY be combined with First -Class Mail® or Priority Malla
■ Certified ail Is not available for any cuss of international mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. Fo
valuables, please considei Insured or Registered Mail.
■ For an additional fee a Rbum Rece/ptmay be requested to provide proof of
delivery. To obtain Re{um,Rdceipt service, please complete and attach a Return
Receipt (PS Form 381ll yto;the article and add applicable postage to cover the
fee. Endorse mailpirace% 'Return Receipt Requested". To receive a fee waiver for
a duplicate return receipt, a USPS® postmark on your Certified Mail receipt is
required. -
■ For an additional fee, delivery may be restricted to the addressee of
addressee's authorized agent. Advise the clerk or mark the mailplece with the
endorsement °Restricted Delivery.
■ If a postmark on the Certified Mail receipt is desired, please present the arti•
cle at the post office for postmarking. If a postmark on the Certified Mai
receipt Is not needed, detach and affix label with postage and mail.
IMPORTANT: Save this receipt and present it when making an inquiry.
Internet access to delivery information Is not available on mail
addressed to APOs and FPOs.

Michael F. Easley, Ghemor �/
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
April 25, 2006
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7003 2260 0001 3493 8989
Pamela Edwards Ford
Hill Haven Residential Care
224 Augusta Drive
Statesville, North Carolina 28625
Subject: Notice of Violation - Effluent Limitations
Tracking #: NOV-2006-LV-0169
Hill Haven Residential Care WWTP
NPDES Permit No. NCO045012
Iredell County
1. Dear Ms. Ford:
.A review of the February 2006 self -monitoring report for the subject facility revealed a violation
of the following parameter:
Pipe Parameter Reported Value Permit Limit
001 Fecal Coliform 2100 colonies/100 ml (daily maximum) 400 colonies/100 ml (daily maximum)
Remedial actions, if not already implemented, should be taken to correct any problems. The
Division of Water Quality may pursue enforcement actions for this and any additional violations. If the
violations are of a continuing nature, not related to operation and/or maintenance problems, and you
anticipate remedial construction activities, then you may wish to consider applying for a Special Order by
Consent. You may contact Mr. John Lesley of this Office for additional information.
If you have questions concerning this matter, please do not hesitate to contact Mr. Lesley or me
at 704/663-1699.
Sincerely,
D. Rex Gleason, P.E.
Surface Water Protection Regional Supervisor
cc: Point Source Branch
Iredell County Health Dept.
JL
Noe Carolina
Niura!!y
Mooresville Regional Office Division of Water Quality Phone [phone] Customer Service
Internet: www.ncwateEgtialiiv.org 610 East Center Ave, Suite 301 Mooresville, NC 28115 Fax [phone]
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper

■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
Print your name and address on the reverse
so that we can return the card to you.
III Attach this card to the back of the mailpiece;
or on the front if space permits.
I. Article Addressed to;
PAMELA EDWARDS FORD —
HILL HAVEN RESIDENTIAL CARE
224 AUGUSTA DRIVE
-STATESVILLE NC 28625
swp/j 1 4/25/06
700� 22L01t0001f049
terlName) 9 C.
D. Is delivery address different from item 1?
If YES, enter delivery address below.
❑ Agent
❑ Addresse,
late of Deliver.
_­3 -6g'
❑ Yes
❑ No
3. Service Type
Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandisi
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
,; ; ; ;,
1891 • !ii ; fi i 1' .
1e e, _ 11204 ii ie F.J. : ; onriA i i I I i I n1 .k e's.. oe+,. oo,..[,r 4noaosso_Kti_Ise

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Sender: Please print your name, address, and ZIP+4 in this box •
�NCDENR
SURFACE WATER PROTECTION
610 CENTER AVE
SUITE 301
MOORESVILLE NC 28115

Nov 07 05 04:36p Pamela Edwards 7048734817 p.2
HILL HAVEN RESIDENTIAL CARE, INC.
142 Oak Haven Dr.
Statesville, North Carolina 28625
November 7, 2005
D. Rex Gleason
Surface Water Protection Regional Supervisor
NCDENR — Division of Water Quality
610 East Center Avenue
Mooresville, North Carolina 28115
Re: Hill Haven Residential Care, Inc.
NPDES Permit No. 0045012
Dear Mr. Gleason:
Per my telephone conversation with Mr. Mike Parker in your office, I am writing to
request Hill Haven's status be changed to active immediately, since the buildings will be
used to house victims of hurricane Katrina.
Thank you for your assistance regarding this matter.
Sincerely,
Pamela Edwards Ford
President

HILL HAVEN RESIDENTIAL CARE, INC.
142 Oak Haven Drive
Statesville, North Carolina 28625
...... ........ ............ .............. .......... .. ...... .... ....... ....... ....... A............... I....\
August 23, 2005
D. Rex Gleason
Surface Water Protection Regional Supervisor
NCDENR - Division of Water Quality
610 East Center Avenue
Mooresville, North Carolina 28115
Re: Hill Haven Residential Care, Inc.
NPDES Permit No. NC0045012
Dear Mr. Gleason:
Thank you for your letter of July 20, 2005.
r
-AUG 2 5 200j'
In a telephone conversation on July 20, 2005? with Mr. Richard Bridgeman of your
office, I was informed that I could request that an inactive status be granted Hill Haven,
since our business has been closed for three years, with no influent flows entering the
treatment facility. Therefore, I am writing to request inactive status.
Hill Haven has paid a testing facility for over three years for testing services, even though
there has been no influent flow into the treatment plant; therefore, I am respectfully
requesting that the inactive status be granted as of August, 2005.
Thank you for your assistance regarding this matter.
Sincerely,
Pamela Edwards Ford
President

Aug 24 05 02:34p Pamela Edwards 7048734817 p.2
HILL HAVEN RESIDENTIAL CARE, INC.
142 Oak Haven Drive
Statesville, North Carolina 2.8625
August 23, 2005
D. Rex Gleason
Surface Water Protection Regional Supervisor
NCDENR - Division of Water Quality
610 East Center Avenue
Mooresville, North Carolina 28115
Re. Hill Haven Residential Cato, Inc.
NPDES Permit No_ NCON5012 r (��c
Dear Mr. Gleason:
Thank you for your letter of July 20, 2005. I
In a telephone conversation on July 20, 2005, with Mr. Richard Bridgeman of your
office, .I was informed that I could request that an inactive status be granted Hill, Haven,
since our business has been closed for three years, with no influent flows entering the
treatment facility. Therefore, I am writing to request ua ctive status.
Dill Haven has paid a testing facility for over three years for testing serviccs, even though
tyre has been no influent flow into the uwtment plant; dwreforc; I amrespecImy
requesting that the inactive status be granted as of August, 2005.
Thank you for your assistance regarding this matter.
Pamela Edwards Ford
President

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:July 20, 2005
MS. .Pamela Edwards Ford
Hill HavenResidentialCare, Inc.
142-Oak Haven Drive
Statesville,-North'Carolina 28625
VU
v/
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and 'Natural Resources
Alan W.' Klimek, P. E., Director
Division of Water Quality
-`Subject: =Compliance Evaluation Inspection
Hill Haven Nursing Home =WWTP
NPDES Permit No: NC0045012
.1redell .County, NC '
Dear Ms. Ford.
Enclosed is a copy of the Compliance Evaluation -Inspection Report for.the inspection conducted at the
subject facility on .July 15, 2005-by'Mr. Wes Bell of.this -Office. Please °inform --the facility's Operator in
f 'Responsible -Charge our findings -by forwarding:a:copy ofthe enclosed report:to him.
'Your residential facility has` been. unoccupied for severalyears with no corresponding influentflows
enteringthetreaunentfacility. Duringyourtelephone,discussionon.July20,'2005-with Mr. :RichardBridgeman
ofthis office you were -advised xo request -;an inactive status be designated for:thesubject.facility. Please be
: advised.that-if:an =inactive :status is granted for ,this facility, you :must ensure that .the treatment plant is fully
operationalpriorto the introduction .ofinfluentwastewater In addition,you must initiate the -appropriate actions
to.ensure.the treatmentplant is restricted from -public access at all .times:(whetheractive or inactive).
The report should beself-explanatory; however,.should.you have any-questions.concerningthis report,
Please -do :not.hesitate .to contact -Mr. -Bell or me at-[phone].
°:Sincerely,
' � D. RexGleason, .E.
Surface Water Protection Regional Supervisor
Enclosure
CC., Iredell County HealthDepartment
1`M 1.1
ftCamlina WKY
CDENR
N_ C Division of Water Quality, Mooresville Regional Office, 610 East Center Avenue, Suite 301, Mooresville.NC 28115 [phone] Customer Service
' 1 C'1'T C17 L'IAO

J, .
United States Environmental Protection Agency
Form Approved.
EPA Washington, D.C. 20460
OMB No. 204"057
Mater Compliance Inspectmon Report
Approval -expires B-31-98
Section A: National Data System Coding i.e., PCS)
Transaction Code NPDES yr/mo/day Inspection Type Inspector Fac Type
1 INI 2 .0 31 NCO045012 I.11 121 05/07/15 j 17 18 U 19 U 20 U
Remarks
211111111111111111111111111111111111111111111111j66
-Inspection Work Days Facility Self -Monitoring Evaluation Rating B1 CIA Reserved -
671 1.5 j 69 70 LI 71-.0 72:U 73 W 74 751 ,I I I I I Li
Section'B: Facility.Data
Name and Location of Facility Inspected (For Industrial'Users dischargingto POTW, also include
Entry Time/Date
Permit.Effecfve Date
POTW name and'NPDES.permit Number)
09:45 AM 05/07/15
05/01/01
Hill Haven Residential Care
Exit Time/Date
Permit. Expiration Date
1116 Hill Haven Rd
Statesville NC 28677
09:56 AM 05/07/15
09/03/31
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax'Number(s)
Other Facility Data
Harry Withers Myers//704-906-2191 /
Jerry L Rogers/ORC/704-872-4697/
Name, Address of Responsible Officialfritle/Phone and Fax Number
Contacted
Pamela Ford,'142 Oak Haven Rd Statesville NC 28625//704-873-4817/
No
Section'C: Areas Evaluated During Inspection (Check only those -areas -evaluated)
Permit ,E Flow -Measurement Operations & Maintenance .M Records/Reports
Self -Monitoring Program Sludge Handling Disposal Facility Site Review ;M.Effluent/Receiving Waters
Laboratory
-Section D: Summary of Finding/Comments Attach additionalsheets of narrative and checklists as necessary)
(See attachment summary)
Name(s) and.Signature(s)of Inspector(s) Agency/Office/Phone and Fax Numbers :Date
Wesley N Bell �/� /� MRO 47Q//704-663-1699 e^,xt.231/
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
Richard M Bridgeman 704-663-1699 Ext.264/
EPA Form 3560-3 (Rev a 94) Previous editions are obsolete.

Permit
(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: The residential facility has not been in operation for several years. The facility does not provide restricted
access.to the public.
(�narationc & R4aintenance
Is the:plant generally clean with acceptable housekeeping?
Does.the facility analyze process control parameters, for ex: MLSS, MCRT,.Settleable Solids, pH, DO, Sludge.Judge,
and other that are:applicable?
`Comment:=Excessive vegetation was observed at•the.plent site. -- The-access:to all treatment units was difficult due to
the:excessiv&vegetation. The•vegetatiomshould be removed and,:propedy-maintained,at'all times.
:Sand Filters (j o_ v rate)
(If pumps are used) Is an audible and visible alarm Present and operational?
Is the distribution box level and watertight?
Is sand filter free of ponding?
Is the sand filter effluent re -circulated at a valid ratio?
Yes No NA NE
❑ ❑ ■ ❑
M'❑ ❑ ❑
❑ -❑ M ❑
.❑■00
-0❑❑❑
Is the sand filter surface free of algae or excessive vegetation?
Is the sand filter effluent re -circulated at a valid ratio? (Approximately 3 to 1)
Comment: The residential facility has not been in operation for several years; therefore, the treatment,facility has not
received any influentflows. The ORC and staff have properly maintained the vegetation in'the on-line filter bed. Note:
The facility is equipped with two filter beds.
_Record Keeping
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?
ME!
Yes "No NA NE
■ '.O �0 ❑
❑ .❑ .❑
❑ :❑ 1❑
❑❑-■❑
-❑❑0❑
'0
,❑
MU ❑ ❑
Has the facility submitted its annual compliance report to users and DWQ?
❑ ❑
❑
IIIIIIII
(If the facility is = or > 5 MGD permitted flow) Do they operate 2417 with a certified operator on each shift?
❑ _❑
.0
O
Is the ORC visitation log available and current?
❑
❑
❑
Is the ORC certified at grade equal to or higher than the facility classification?
M ❑
.❑
, ❑
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?
❑ E
❑
❑
Facility has copy of previous year's Annual Report on file for review?
❑ ❑
❑
M
'Comment: DMRs were reviewed from March 04 through April 05. Appropriately documented DMRs continue to be
submitted while the residential facility is not currently in operation. A copy of the Permit is not kept at the treatment plant;
however, -.the ORC keeps a copy of the Permit. The ORC and staff incorporate a commendable record keeping system.
Yes
No
NA
NE
Effluent Sam Ip ino
Is composite sampling flow proportional?
❑ 13
M
13

Effluent Sam I,� inn
Is sample collected below all treatment units?
Is proper volume collected?
Is the tubing clean?
Is proper temperature set for sample storage (kept at 1.0 to 4.4 degrees Celsius)?
Is the facility sampling performed as required by the permit (frequency, sampling type representative)?
-Comment: The ORC and staff still visit the facility as required by the Permit.
Fffh iPnt Pipe
Is right of way to the outfall. properly maintained?
Are the receiving waterfree of foam other than trace amounts and other debris?
If effluent (diffuser -pipes are required) are -they operating properly?
Comment:.Thefacility has not discharged in several .years.
Yes No NA NE
❑ ❑ ■ ❑
❑ ❑ ■ ❑
❑ ❑ :■ ❑
❑O•■❑
❑ .❑ ❑
Ypc_ No NA NF
❑ ❑ ❑
-❑ :❑ N ❑
:❑ ;❑ ■ ❑

O� wAT Ot�qQG
r
Coleen H. Sullins, DeputyDirector
Division of Water Quality
Michael F. East Governor
William G. Ross Jr., Secretary .
North Carolina Department of Environment and Natural Resources
Alan W. Klimek; P. E. DhWor
Division of Water Quality
June -8, 2004
Mrs.. Pamela EdwardsFord
Hill Haven Residential Care, Inc.
142 Oak Haven Drive
Statesville, North Carolina 28625
Subject: Compliance Evaluation Inspection
Hill Haven Nursing Home WWTP
NPDES Permit No. NCO045012
Iredell County, NC
Dear Mrs. Ford:
Enclosed is a copy of the Compliance Evaluation Inspection Report for the inspection
conducted at the subject facility on May 26, 2004 by Mr. Barry Love of this Office. Please
inform the facility's Operator -in -Responsible Charge of our findings by forwarding a copy of
the enclosed report. '
Your NPDES permit expires on July 31, 2004. Please note that if your permit is not
renewed and is allowed to lapse, the reopening of your facility in the future would require
application for and issuance of a new permit.
The report should be, self-explanatory; however, should you have any questions
concerning this report, please do not hesitate to contact Mr. Love or me at [phone].
Sincerely,
D. Rex Gleason, P.E.
Water Quality Regional Supervisor
Enclosure
cc: Iredell County Health Department
Division of Water Quality, Mooresville Regiorral office, 919 North Main Street, Mooresville NC 28115 [phone] Cum Service
1-8 n-623-6748

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= u 2 U 31 NCO045012 111 121 04/05/26 117 18 u 19 u 20 u
Remarks
2T 1IIII1111111111111111111111111111111111 11111-1I66
Inspection Work Days Facility Setf-Monitoring Evaluation Rating B1 CIA ----------Reserved ---
6� 2.0 169 70 U 71 L'_I 72 U 73 u 74 751 I I I I I Li 80
Section B: Facility Data
Namocatio e and Location of Facility Inspected (For Industrial Users discharging to POTW, also include
Entry Time/Date
Permit Effective Date
name and NPDES permit Number)
Hill Haven Residential Care
02:55 PM 04/05/26
00/03/01
Exit rime/Date
Permit Expiration Date
1116 Hill Haven Road
Statesville NC 28677
03:15 PM 04/05/26
04/07/31
Name(s) of Onsite Representative(s)Mtles(s)/Phone and Fax Number(s)
Other Facility Data
Jerry L Rogers/ORC/704-872-4697/
Dena C Myers//704-872-4697 /
Name, Address of Responsible Official/Title/Phone and Fax Number
Pamela _ord,142 Oak Eaver. Rd Statesville NC 28625//704-873-4817/ Contacted
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit N Flow Measurement Operations & Maintenance 0. Records/Reports
Self -Monitoring Program N Facility Site Review Effluent/Receiving Waters 1 Laboratory
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
(See attachment summary)
Names) anted Signature(s) of Inspector(s) Agency/Office/Phone and Fax Numbers D to
���/� 114
Barry F Love MRO WQ//704-663'-1699/704-663-6040
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
Richard M Bridgeman 704-663-1699/704-663-6040
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.

NPDES ydmo/day Inspection Type 1
31 NCO045012 I �� 12 I 44/05./26 117 �18 L`J
Section D. Summary of Findin"mments (Att2ch additional sheets of narrative and cheddists as necessary)
The facility has been out of operation=and no discharge has been reported since March 2003. The plant was
not discharging at the time of t e�inspection, and the stream was not visibly impacted. Minimal vegetation was
observed on the sand filter. Th bRC has continued to visit the plant in accordance with permit requirements.
Records are well maintained.
� Ik_
y _

u
i
i
Permit NCO045012 Owner - Facility: Hill Haven Residential Care - Hill Haven kesidential Care
Inspection Date: 05/26/04 Inspection Type: Compliance Evaluation
Permit Yes No NA NE
(if the present permit expires in 6 months or less). Has the pernittee submitted a new appoation? ❑ 0 ❑ ❑
Is the facility as described in the permit? _ . ❑ ❑ ❑
Are there any special conditions for the permit? I`
Is access to the plant site restricted to the general public? I1 _ ❑ ❑ ❑
Is the inspector granted access to all areas for inspection?d� ❑ ❑ ❑
Comment:The permit expires on July 31, 2014. No permit renewal application has been r`Rmwed,
I,
Onerations & Mnint .nan .e Yes No NA NE
Does the plant have general safety structures in place such as rails around or covers ov L of ; or wells? ❑ ❑ ❑
Is the plant generally dean with acceptable housekeeping? ❑ SO ❑
_.
Comment:Vegetadon has grown around the plant since the facility has closed down. -
I

Hill Haven Residential Care, Inc.
Wastewater Treatment Plant
Annual Performance Report
For the Calendar
Year 2003 .

Name of System:
NPDES# M L
Annual Performance Report
Notification Certification Form
7 7 � r i
I confirm that the Annual Performance Report has been made available
to customers and that the information is correct and consistent with the
compliance monitoring data previously submitted to the DWQ.
The information was made available:
Posted on the Internet
Mailed the report to customers
Posted on the bulletin board in the office
Document made available for review at
Certified By:
Name
Title
1bq-5?F13,N r Date
VokCN ;i t
=WW—Ragn

Hill Haven Residential Care, Inc.
Operator Responsible in Charge:
Jerry Rogers
Statesville Analytical, Inc.
122 Court St.
PO Box 228
Statesville, NC 28687
Contact Person:
Ms. Pamela Edwards
Hill Haven Residential Care, Inc.
114 Hill Haven Road
Statesville, NC 28677
I. General
The treatment system is an existing 0.018MGD wastewater
treatment facility with the following components:
• Two Septic tanks
• Two surface sand filters
• Effluent chlorination
This facility is , located at Hill Haven Residential Care at 114 Hill
Haven Road near Statesville in Iredell County. Discharge from Hill
Haven Residential' Care wastewater facility is received into and
unnamed tributary to Third Creek, classified C waters in the Yadkin -
Pee Dee River Basin.

II. Compliance Performance:
The North Carolina Department of Environment and Natural
Resources (NCDENR) regulates the Hill Haven Residential Care, Inc.
effluent discharge under the National Pollutant Discharge Elimination
System (NPDES). The NCDENR issued to Hill Haven Residential
Care, Inc. a NPDES Permit that includes water quality limits and
sampling and monitoring requirements. The NPDES permits requires
Hill Haven Residential Care, Inc. to test for. routine wastewater
parameters of the treated water leaving the wastewater facility. The
monitoring frequency for these tests is set at various intervals as set
forth in the permit.
During the year 2003 no test were completed due to "No Activity".
Parameter
Flow
Biochemical Oxygen
Demand (BOD)
Number
Tests
Required"
Number
Tests
Conducted
Average
Results
Monthly Permit
Limit
0.0018 MGD
30.0 mg/L
otal Suspended Solids
30.0 mg/L
9.4 mg/L
s Nitrogen
ber
30.0 mg/L
FaN
s Nitrogench
200 CFU/100
orm
mL
Total Residual Chlorine
No limit
No limit
Temperature
>=6, <9
pH
No limit
Total nitrogen -
No limit
Total Phosphorus

III. Certification:
I have personally examined and am familiar with the information
submitted in this document. Based upon my inquiry of those
individuals immediately. responsible for obtaining the information
reported herein, I believe that the submitted information is true,
accurate, and complete. I am aware that there are significant penalties
for submitting false information.
Signed this ; �, LL day of t t C 12004

MEMO.
r
DATE: pj
/
O 19
TO: ! �-��
SUBJECT:
U VVI -4?,- fo 1-� ca �) o-�
a K ej
WC1
Gow�et�PI2d
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t--e—C-ea-IV e� ; i-�
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From: v / L— © w
North Carolina Department of Environment
Health and Natural Resources
QflM1 Printed on Recycled Paper

Michael F. Easley
O�O� W A7F9QG Qp�A Governor
vj y NCDENR William G. Ross, Jr., Secretary
t_ North Carolina Department of Environment and Natural Resources
'< Alan W. Klimek, P.E., Director
Division of Water Quality
January 5, 2004
Pamela Ford
Hill Haven Residential Care
142 Oak Haven Road
Statesville, NC 28625
Subject: Renewal Notice
NPDES Permit NC0045012
Hill Haven Residential Care WWTP
Iredell County
Dear Permittee:
Your NPDES permit expires on July 31, 2004. Federal (40 CFR 122.41) and North Carolina (15A NCAC 2H.0105(e))
regulations. require that permit renewal applications must be filed at least 180 days prior to expiration of the current permit: If
you have already. mailed your renewal application, you may disregard this notice.
To satisfy this requirement, your renewal package must be sent to the Division postmarked no later than February 2,
2004.' Failure to request renewal of the permit by this date may result in- a civil assessment of. at least $500.00. Larger penalties
may be assessed depending upon the delinquency of the request.
If any, wastewater discharge will occur after July 31, 2004, the current permit must be renewed. Discharge of wastewater
without a valid permit would violate North Carolina General Statute 143-215:1; unpermitted discharges of'wastewater may result
in assessment of civil penalties of up to. $25,00.0 per day.
If all wastewater discharge has ceased at your facility and you wish to rescind this permit, contact Bob Sledge of the
Division's Compliance Enforcement Unit at [phone], extension 547. You may also contact the Mooresville Regional
Office at [phone] to begin the rescission process.
Use the enclosed checklist to complete your renewal package. The checklist identifies the items you must submit with
the permit,renewal application. If you have any questions, please contact Valery Stephens at the telephone number or e-mail
address listed below.
cc: Central Files
Mooresville Regional Office, -Water Quality. Section
NPDES File
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Visrr us ON THE INTERNET @ http://h2o.enr.state.nc.us/NPDES
Sincerely,
- OF f=NV16�0�.�9tNT
_ _1'1`,'E7 7 ;., ;,ESOURCES
Charles H. Weaver, Jr. ^!4,1 OFFICE
NPDES Unit
p-
f.
.t
919 733-5083, extension 520 (fax) 919 733-0719
e-mail: [e-mail]

NPDES Permit NCO045012
Hill Haven Residential Care WWTP
Iredell County
The following items are REQUIRED for all renewal packages:
❑ A cover letter requesting renewal of the permit and documenting any changes at the facility since
issuance of the last permit. Submit one signed original and two copies.
❑ The completed application form (copy attached), signed by the permittee or an Authorized
Representative. Submit one signed original and two copies.
❑ If an Authorized Representative (such as a consulting engineer or environmental consultant) prepares
the renewal package, written documentation must be provided showing the authority delegated to any
such Authorized Representative (see Part II.B.11.b of the existing NPDES permit).
❑ A narrative description of the sludge management plan for the facility. Describe how sludge (or other
solids) generated during wastewater treatment are handled and disposed. If your facility has no such
plan (or the permitted facility does not generate any solids), explain this in writing. Submit one signed
original and two copies.
The following items must be submitted by any.Municipal or Industrial facilities discharging
process wastewater:
Industrial facilities classified as Primary Industries (see Appendices A-D to Title 40 of the Code of Federal
Regulations, Part 122) and ALL Municipal facilities with a permitted flow >_ 1.0 MGD must submit'a
Priority Pollutant Analysis (PPA) in accordance with 40 CFR Part 122.21.
The, above requirement does NOT apply to privatelyowned.faciU es treating 100.%:
domestic wastewater, or facilities which discharge non process wastewater (cooling
water, filter backwash, etc.)
PLEASE NOTE:
Due to a change in fees effective January 1, 1999, there is no renewal fee required with your
application package.
Send the completed renewal package to:
Mrs. Valery Stephens
NC DENR / Water Quality / Point Source Branch
1617 Mail Service Center
Raleigh, NC 27699-1617

Dl=pT. of E{V1i G �C
AND NATURAL RESOURCES
Hill Haven Residential Care, Inc. MOORESVILLE REGIGNA, ®EEIOE
C/O Pamela Edwards Ford 0/�
'` a
142 Oak Haven Drive
Statesville, NC 28625 ' J r10 12 2003
June 10, 2003
WATER'Lo
RE: Notice of Violation
Hill Haven Residential Care
NPDES Permit No. NC 0045012
Mr. Richard Bridgeman
NCDENR
919 North Main Street
Mooresville, NC 28115
Dear Mr. Bridgeman:.
The f611 or response is -per youurequesij 'your letter dated May30� 2UO3:
PLAN OF CORRECTION
Facility Site Review/Operations and Maintenance:
Statesville Analytical had recently done approximately 6 hours of work at the facility
regarding weed removal.The surrounding grounds will be cleared of vegetation and a
clear path will be made for entrance to the site, as well as to the chlorination chamber.
Completion date 6-20-03
A secured lid will be placed on top of the chlorination chamber.
Completion date 6-20-03
Self -Monitoring Report:
Prior to September 1, 2003, Tom Kincaid, the leasee of Hill Haven, had contracted with
Overcash Environmental. I tried to reach Steve Overcash, to no avail, to get copies of the
records. Statesville, Analytical was hired in September, 2002. Tom
K.incaiii closed-th&faci1ity on March 17, 2003. I presently have a contract with
Statesville Analytical to provide operational services. There are two DMR
Reports that have been amended by 'Statesville Analytical' and Have been iriailed to you.
Completion date 6-10-03

4.

It is obvious that Tom Kincaid's operator, Steve Overcash, was not reporting according
to the permit requirements. When Mr. Kincaid closed the facility in March, 2003, I
immediately hired Statesville Analytical in an effort to assure that permit requirements
are met.
This facility is presently closed and non -operational.
Sincerely,
Pamela Edwards Ford, President
Hill Haven Residential Care, Inc.

n
Postage
Q
$
CRi O`
L! Certified Fee
Q
L�
L m
Po irk co
Return Receipt Fee
r (Endorsement Required)
f Hgja�
4 P'
,
Restricted Delivery Fee
7 (Endorsement Required)
7 Ti
-1 VIRS PAIvMLA FORD
un Tee�L HAvEN RESIDENTIAL CARE, INC.
'
---- 42 OAK HAVEN RD '-------------
5,6STATESVII.LE NC 25625 ..............
y wq/wb 5/30/03

Certified Mail Provides:
■ A mailing receipt
■ A unique identifier for your mailpiece
■ A signature upon delivery
■ A record of delivery kept by the Postal Service for two years
Important Reminders:
■ Certified Mail_may ONLY be combined with First -Class Mail or Priority Mail.
■ Certified Mail is not available for any class of international mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. Fo
valuables, please consider Insured or Registered Mail.
■ For an additional fee, a Return Receipt may be requested to provide proof o
delivery. To obtain Return Receipt service, please complete and attach a Returr
Receipt (PS Form 3811) to the article and add applicable postage to cover the
fee. Endorse mailpiece to
Receipt Requested". To receive a fee waiver fo
a duplicate return receipt, a USPS postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee o
addressee's authorized agent. Advise the clerk or mark the mailpiece with the
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■ If a postmark on the Certified Mail receipt is desired, please present the arti
cle at the post office for postmarking. If a postmark on the Certified Mai
receipt is not needed, detach and affix label with postage and mail.
IMPORTANT: Save this receipt and present it when making an inquiry.
PS Form 3800, January 2001 (Reverse) 102595-01-M-104!

P7 Michael F. Easley, Governor
r William G. Ross, Jr -Secretary
-i North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E., Director
Division of Water Quality
May 30, 2003
70012510 0004 8287 6685
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
Mrs. Pamela Ford
Hill Haven Residential Care, Inc.
142 Oak Haven Road
Statesville, North Carolina 28625
Subject: Notice of Violation ,
Compliance Evaluation Inspection
Hill Haven Nursing Home WWTP
NPDES Permit No. NCO045012
Iredell County, N.C.
Dear Mrs. Ford:
Enclosed is a copy of the Compliance Evaluation Inspection Report for the inspection
conducted at the subject facility on May 20, 2003 by Mr. Wes Bell of this Office. Please inform the
facility's Operator in Responsible Charge of our findings by forwarding a copy of the enclosed report
to him.
This report is being issued as a Notice of Violation (NOV) for the numerous monitoring
violations of the subject NPDES Permit and North Carolina General Statute (G.S.) 143-215.1 as
detailed in the Self -Monitoring Section of the attached report. Pursuant to G.S. 143-215.6A, a civil,
penalty of not more than twenty-five thousand dollars ($25,000.00) per violation, per day may be
assessed against any person who violates or fails to act in accordance with the terms, conditions, or
requirements of any permit issued pursuant to G.S. 143-215.1.
It is requested that a written response be submitted to this Office by June 20. 2003,
addressing the deficiencies noted in the Facility Site Review/Operations and Maintenance and
Self -Monitoring Sections of the report. In responding please address your comments to the
attention of Mr. Richard Bridgeman.
Mooresville Regional Office, 919 North Main Street, Mooresville, NC 28115
NDrNR
[phone]
[phone]
Customer Service
1 800 623-7748

Notice of Violation
Mrs. Pamela Ford
Page Two
The report should be self-explanatory; however, should you have any questions concerning
this report, please do not hesitate to contact Mr. Bell or me at [phone].
Sincerely,
D. Rex Gleason, P.E.
Water Quality Regional Supervisor
Enclosure
cc: Iredell County Health Department
up

United States Environmental Protection Agency
Form Approved.
t �� Washington, D.C. 20460
OMB No. 2040-0057
Water Compliance Inspection Report
Approval expiresB-31-98
Section A: National Data System Coding (i.e., PCS)
Transaction Code NPDES yr/mo/day Inspection Type Inspector Fac Type
1 I„I 2 I s I 3I NC0045012 111 121 03/05/20 117 18 I I 19 I C I 20 Li
LI LJ LJ LJ
Remarks
211111111111111111111111111111111111111111111II1166
Inspection Work Days Facility Self -Monitoring Evaluation Rating B1 CIA —Reserved
67 I i.0 169 70 J3 I 71 I„ 72 I„ 73 � 75I I 180 I I 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 permit Number)
03:10 PM 03/05/20
00/03/01
Hill Haven Residential Care
Exit Time/Date
Permit Expiration Date
1116 Hill Haven Road
Statesville NC 28677
03:45 PM 03/05/20
04/07/31
Name(s) of Onsite Representative(s)Ttles(s)/Phone and Fax Number(s)
Other Facility Data
Jerry L. Rogers/ORC/704-878-0459/
Dena Myers//704-872-4697/
Name, Address of Responsible Officialrritle/Phone and Fax Number
Contacted
Pamela Ford,142 Oak Haven Road Statesville NC 28625//704=873-4817/
No
Section C: 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 oT narrative and checklists as necessary)
PERMIT:
The permit description adequately describes the facility. A permit modification was issued by the
Division on 4/2/01 regarding a change in the sampling frequency for effluent temperature from daily to
weekly.
RECORDS AND REPORTS:
DMRs, chain of custody forms, laboratory analyses, calibration data, Operator in Responsible Charge (ORC1
(co ast.)
visitation to g, and maintenance log were reviewed at the laboratory facility of the current contract
operations firm_ All records were accessible and
Name(s) and Signature(s) of Inspector(s) Agency/Office/Phone and Fax Numbers Date
Wesley N Bell MRO WQ//704-663-1699/704-663-6040
-5/29/0
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.

NPDES yr/mo/day Inspection Type (cont.
) 1
31 NC0045012 111 12' 03/05/20 117 18 I d
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
well maintained.
FACILITY SITE REVIEW/OPERATIONS & MAINTENANCE:
The facility's business operations have ceased since March 13, 2003. There are currently no patients or
employees at this facility. Only one septic tank and sandfilter were utilized during operation- The
surrounding grounds were heavily vegetated. In addition, the chamber that houses the tablet chlorinator
did not have a cover (noted in the 3/23/01 inspection report)- Sticks, leaves, etc. was observed ins -de
of the chamber. A lid should be placed on top of this chlorination chamber to prevent the accumulation
of -debris and to remove a potential safety hazard. Please be advised that the Permit requires that the
facility be properly operated and maintained at all times. The permittee must ensure that adequate
equipment is provided to properly operate and maintain the facility at all times. The facility hired a
new contract operations firm (beginning September 2002) to assume the duties associated with the NPDES
Permit. The facility is staffed with appropriately certified operators. The ORC and staff were very
knowledgeable of all treatment processes and equipment utilized at this facility.
LABORATORY:
Statesville Analytical (Certification #440) of Statesville, N.C. has been contracted to provide
analytical support. All on -site field analyses'are performed under the certified laboratory's
certification. The laboratory instrumentation utilized for field analyses appeared to be properly
calibrated.
EFFLUENT/RECEIVING WATERS:'
The facility was not discharging at the time of the inspection. The discharge outfall was heavily
vegetated, but accessible at the time of the inspection. The nermittee and ORC must ensure that the
discharge outfall is accessible for sample collection/analysis and inspection_ of the receiving stream.
SELF -MONITORING PROGRAM:
Self -monitoring reports were reviewed for the period April 2002 through March 2003, inclusive. Note:
The facility hired a new contract, operations firm in September 2002. A daily maximum fecal coliform
violation was reported on August 13, 2002. The Division has previously addressed this violation. The
following monitoring violations were noted:
- No effluent total nitrogen and total phosphorus were reported for the third quarter of 2002.
- Only one TRC value was reported for the weeks of June 30 through July 6, July 7 through July 13, July
14 through July 20, July 21 through July 27, July 28 through August 3, the entire month of August 2002,
and December 29, 2002 through January 4, 2003.
No operator time on -site was documented on April 25, 2002. The compliance status was not checked for the
June 2002 DMR. The back of the September 2002 DMR was not completely documented. The phrase "no flow"
was reported on September 24 and 25; however, pE and TRC values were reported. A 117.1" mg/l TRC value
was reported on January 13, 2003; however, this value appears to be a transcription error (TRC values
typically ranged from 0-5 - 0.7 mg/1 at this facilitv). The ORC and permittee must ensure that all DNRs
are accurate and complete before submittal to the Division. Please resubmit amended DMRs if any of the
above noted discrepancies were transcription errors.
All samples (reviewed at the laboratory) appeared to be properly preserved and meet the required holding
times.
FLOW MEASUREMENT:
The flog.' is measured instantaneously by the bucket and stop watch method. The facility has not
incorporated a dose cou:-iter measurement system as recommended ir. previous inspection reports.
SLUDGE DISPOSAL:
i
Septage was last removed by Lentz Septic Tank Service, Inc. of Statesville, N.0 and disposed at an

NPDES yr/mo/day Inspection Type (cont.) 2
3I NCO045012 111 121 03/05/20 117 18 ICI
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
approved land application site in Iredell County.

■ Completejterfls 1, 2, and 3. Also complete
item•4 if Restricted Delivery is desired.
Print your name and address on the reverse
so that we can return the card to you.
Attach this card to the back of the mailpiece,
or on the front if space permits.
Article Addressed to:
/IRS PAMELA FORD -
ELL -HAVEN RESIDENTIAL CARE, INC.
42 OAK HAVEN RD
;TATESVILLE NC 28625
vq/wb 5/30/03
❑ Agent
ddressei
C. Date of De i
D. Is delivery address different from item 1? ❑ Ye:
If YES, enter delivery address below: ❑ No
Service Type
Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
t 1tt i {ttSt i { itt t it '
70101 2510 OD04.M'M { a6685:ai
IS Form 381,1,, August 2001 Domestic Return Receipt 102595-01-M-251

UNITED STATES POSTAL SERVICE`0t? Y �,`� �- -"-- irst-Class ail
Pos�� & Fees Paid
M — -- —LISPS --=—
Permit No. G-10
• Sender: Please print yoi%.n,acne; address, and ZIp_�`.�_ in this box -
DENK
WATER QUALITY SECTION.,
919 NORTH MAIN STREF ® m
MOORESVILENC 28115 LA
'a F
2 E9

i
State of North Carolina
Department of Environment t> • •
and Natural Resources
Division of Water Quality %
M, ichael F. Easley, Governor
Willam G. Ross Jr., Secretary N--ACDENR
Alan Klimek, P.E., Director NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
"V
March 12, 2003
MR. TOM KINCAID, ADMINSTRATOR
4876 BOY SCOUT CAMP RD
KANNAPOLIS , NC 28081 t
SUBJECT: PAYMENT ACKNOWLEDGEMENT
CIVIL PENALTY ASSESSMENT
HILL HAVEN RESIDENTIAL CARE
IREDELL COUNTY
PERMIT NO: NCO045012
LV 03-118
Dear Mr. Kincaid:
This letter is to acknowledge receipt of check No. 6126 in the amount of $335.45 received from
you dated March 01, 2003. This payment satisfies in full the civil assessment levied against
the subject facility and this case has been closed. Payment of this penalty in no way precludes future
j action by this Division for additional violations of the applicable Statutes, Regulations or Permits.
If you have any questions, please call Bob Sledge at [phone].
Sincerely,
a
-. Pam.
• ��A R
per,:
Coleen Sullins, Chief = U
O-Water Quality Section
8 2003
Enforcement File #: LV 03 -118
�MRO Regional Office Supeivisor
Central Files
1617 Mail Service Center, Raleigh, NC 27699-1617
An Equal Opportunity Affirmative Action Employer
WATER QUALITY lFunu
Telephone [phone] Fax [phone]
50% recycled/10% post -consumer paper

Postage
Certified Fee
dfi �PEstmark .
Return Receipt Fee tt( C'Werie
(Endorsement Required)
Restricted Delibery Fee L
(Endorsement Required)
TMR TOM KINCAID, ADMINISTRATOR-
se'HILL HAVEN RESIDENTIAL CARE
sin114 HILL HAVEN RD --------------
c�hSTATESVILLE NC 25677 •_____________
wq/nAW2/12/03--

Certified Mail Provides:
r A mailing receipt
■ A unique identifier for your mailpiece
■ A signature upon delivery
■ A record of delivery kept by the Postal Service for two years
mportant Reminders:
■ Certified Mail may ONLY be combined with First -Class Mail or Priority Mail.
® Certified Mail is not available for any class of international mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. Fo
valuables, please consider Insured or Registered Mail.
■ For an additional fee, a Return Receipt may be requested to provide proof o
delivery. To obtain Return Receipt service, please complete and attach a Returr
Receipt (PS Form 3811� to the article and add applicable postage to cover thr
fee. Endorse mailpiece 'Return Receipt Requested". To receive a fee waiver fo
a duplicate return receipt, a USPS postmark on your Certified Mail receipt i;
required.
■ For an additional fee, delivery may be restricted to the addressee o
addressee's authorized agent. Advise the clerk or mark the mailpiece with thr
endorsement "Restricted Delivery".
0 If a postmark on the Certified Mail receipt is desired, please present the arti
cle at the post office for postmarking. If a postmark on the Certified Mai
receipt is not needed, detach and affix label with postage and mail.
IMPORTANT: Save this receipt and present it when making an inquiry.
IS Form 3800, January 2001 (Reverse) 102595-01-M-104!

,� WATF L/
\O�� RpG Michael F. Easley
Governor
co William G. Ross, Jr.,Secretary
>_ North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E., Director
Division of Water Quality
i
February 12, 2003
CERTIFIED MAIL
RETURN RECEIPT REQUESTED 70012510 0005 0287 8569
Mr. Tom Kincaid, Administrator
Hill Haven Residential Care, Inc.
114 Hill Haven Road
Statesville, NC 28677
SUBJECT: Notice of Violation and Assessment of Civil
Penalty for Violations of N.C. General Statute
143-215.1(a)(6) and NPDES Permit No. NCO045012
Hill Haven Residential Care, Inc. WWTP
Case No. LV 03-118
Iredell County
Dear Mr. Kincaid:
This letter transmits a Notice of Violation and assessment of civil penalty in the amount
of $335.45 ($250.00 civil penalty + $85.45 enforcement costs) against Hill Haven Residential
Care, Inc.
This assessment is based upon the following facts: A review has been conducted of the
discharge monitoring report (DMR) submitted by Hill Haven Residential Care, Inc. for the
month of August 2002. This review has shown the subject facility to be in violation of the
discharge limitations found in NPDES Permit No. NC0045012. The violations are summarized
in Attachment Ato this letter.
Based upon the above facts, I conclude as a matter of law that Hill Haven Residential
Care, Inc. violated the terms, conditions or requirements of NPDES .Permit No. NCO045012 and
North Carolina General Statute (G:S.) 143 215.1(a)(6) in the manner and extent shown in
Attachment A. A,civil penalty may be assessed in accordance with the maximums established by G.S. 143-215.6A(a)(2).
. Based upon the above findings of fact and conclusions of law, and in accordance with
authority provided by the. Secretary of the Department of Environment and Natural Resources
and the Director of the Division of Water Quality, I, D. Rex Gleason, Water Quality Regional
Supervisor for the Mooresville Region, hereby make the following civil penalty assessment
against Hill Haven Residential Care, Inc.:
ti D. MR
Customer Service Mooresville Regional Office, 919 North Main Street, Mooresville, NC 28115 PHONE [phone]
800 623-7748 FAX [phone] .

$ 2 T `% For t,' of the one (1) violation of G.S. 143
215.1(a)(6) and NPDES Permit No. NC0045012, by
discharging waste into the waters of the State in
violation of the permit daily maximum effluent
limit for Fecal Coliform.
2
$ 85.45
TOTAL CIVIL PENALTY
Enforcement costs.
TOTAL AMOUNT DUE
Pursuant to G.S. 143-215.6A(c); in determining the amount of the penalty I have taken
into account the Findings of Fact and Conclusions of Law and the factors set forth at G.S. 143B-
2 82. 1 (b), which are:
(1)
(8)
The degree and extent of harm to the natural resources of the State, to the public
health, or to private property resulting from the violation;
The duration and gravity of the violation;
The effect on ground or surface water quantity or quality or on air quality;
The cost of rectifying the damage;
The amount of money saved. by noncompliance;
Whether the violation was committed willfully or intentionally;
The prior record of the violator in complying or failing to comply with programs
over which the Environmental Management Commission has regulatory
authority; and
The cost to the State of the enforcement procedures.
Within thirty days of receipt of this notice, you must do one of -the following:
1. Submit payment of the penalty:
Payment should be made directly to the order of the Department of Environment
and Natural Resources (do not include waiver form). Payment of the penalty will
not foreclose further enforcement action for any continuing or new violation(s).
Please submit payment to the attention of:
Point Source Compliance/Enforcement Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1.617
2. Submit a written request for remission or mitigation including a detailed
justification for such request: ,

A request for remission or mitigation is limited to consideration of the
reasonableness of the amount of the penalty and is not the proper procedure for
contesting the accuracy of any of the statements contained in the assessment
letter. Because a remission request forecloses the option of an administrative
hearing, such a request must be accompanied by a waiver of your right -to an
administrative hearing -and a stipulation that there are no factual or legal issues in
dispute. You must execute and return to this office the attached waiver and
stipulation form and a detailed statement which you believe establishes whether:
(a) one or more of the civil penalty assessment factors in G.S. 143B-282.1(b)
were wrongfully applied to the detriment of the petitioner;
(b) the violator promptly abated continuing environmental damage resulting
from the violations;
(c) the violations were inadvertent or a result of an accident;
(d) the violator had been assessed civil penalties for any previous violation;
(e) payment of the civil penalty will prevent payment for the remaining
necessary remedial actions.
Please submit this information to the attention of.
Ms. Coleen Sullins
Water Quality Section Chief
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Please note that all information presented in support of a request for remission
must be submitted in writing. The Director of the Division of Water Quality will
review the information during a bimonthly enforcement conference and inform
you of his decision in the matter of the remission request. His response will
provide details regarding case status, directions for payment and provision for
further appeal of the penalty to the Environmental Management Commission's
Committee on Civil Penalty Remissions. Please be advised that the Committee
cannot consider information that was not part of the original remission request
considered by the Director and therefore, it is very important that you prepare a
complete and thorough statement in support of your request for remission.
KO
3. Submit a written request for an administrative bearing:
If you wish to contest any statement in this assessment letter, you must request an
administrative hearing. This request must be in the form of a written petition to
the Office of Administrative Hearings and must conform to Chapter 150B of the
North Carolina General Statutes. You must:

File your original petition with the
Office of Administrative Hearings
6714 Mail Service Center
Raleigh, North Carolina 27699-6714
and
Mail or hand -deliver a copy of the petition to
Mr. Dan Oakley, General Counsel
Department of Environment and Natural Resources
1601 Mail Service Center
Raleigh, North Carolina 27699-1601
Failure to exercise one of the options above within thirty days, as evidenced by a date
stamp (not a postmark) indicating when we received your response, will result in this matter
being referred to the Attorney General's Office with a request to initiate a civil action to collect
the penalty.
Please be advised that any continuing violation(s) may be the subject of a new
enforcement action, including an additional penalty. If you have any questions about this civil
penalty assessment, please contact the Water Quality Section staff of the Mooresville Regional
Office at 704/663-1699.
i z 2 � �.3
(Date)
ATTACHMENTS
D. Rex Gle on, P.E.
Water Quality Regional Supervisor
Mooresville Regional Office
Division of Water Quality
cc: Water Quality Regional Supervisor w/ attachments
-ComplianceMnforcement File w/ attachments
Central Files w/ attachments

Limit Violations, August 2002
Parameter
Attachment A
Hill Haven Residential Care, Inc.
NPDES Permit No. NC0045012
Case Number LV 03-118
Daily Maximum Limit Violations
Reported Value Limit Units
Fecal Coliform 580 * 400. #/100 ml-
* denotes assessment of civil penalty.

STATE OF NORTH CAROLINA
COUNTY OF Iredell
DEPARTMENT OF ENVIRONMENT
AND NATURAL RESOURCES
1
IN THE MATTER OF ASSESSMENT ) WAIVER OF RIGHT TO AMOF
CIVIL PENALTIES AGAINST ) ADMINISTRATIVE HEARING
AND STIPULATION OF FACTS
Hill Haven Residential Care, Inca )
PERMIT NO. NC0045012 ) FILE NO. LV 03-118
Having been assessed civil penalties totaling for
violation(s) as set forth: in the assessment document of the Division of Water Quality dated
.-the undersigned, desiring to seek remission of the civil
penalties, does hereby waive the right to an administrative hearing in the above -stated matter and
does stipulate that the facts are as alleged in the. assessment document. The undersigned further
understands that all evidence presented in: support of remission of this civil penalty mustbe
submitted to the Director of the Division of Water Quality within 30-days of receipt of the notice
of assessment. No new evidence in support of a remission request will be allowed after 30 days
from the receipt of the notice of assessment.
This the day of 2003
ADDRESS

Permit CU0 50 2
i
A. (1.) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS
During the period beginning on the effective date of the 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:
EFFLUENT CHARACTERISTICS
LIMITS
MONITORING REOUIRENfEt�TS.
lll7nnthf :-
_;.
Daily
_;.11azimum
Measurement
Frequency
Sample Type
Sample catlnn
-- 4._,, _.�
Flow
0.01 B MGD
Weekly
Instantaneous
Influent or Effluent
BOD, 5 day (202C)
30.0 ma/L .
45.0 ma/L
2/Month
Grab
Effluent
Total Suspended Residue
30.0 mg/L
45.0 mg/L
2/Month
Grab
Effluent
NH3 as N (April 1— October 31)
9.4 mg/L
2/Month
Grab
Effluent
NH3 as N (November 1 — March 31)
30.0 ma/L
I
I
JMonth
Grab
,
.Effluent
Fecal CoVorm (geometric mean)
2001100 ml
I 400/100 mi
2/Month
Grab
Effluent
Total Residual Chlorine
2/Week
Grab
Effluent
Temperature (°C)
i
I
I Weekly
Grab
J
Effluent
i Total Nitrooen
(ND2+NO3TKN)
j
I
j
Quarterly
Grab
i 'Effluent
Total phosphorus
i
( Quarterly
Grab
Effluent
py1
I
I
I 2/Month
Grab
Effluent
Footnotes:
1. The pH shall not be less than 6.0 standard units nor greater than 9.0 standard units.
There shall be no discharge of floating solids or Visible foam in other than trace amounts.

EFFLUENT
NTDE7S PERMIT NO. r1Q­0c L5,--
DISCHARGE NO. c-,v MON TH YEAR
FACILITY NAME V�s-,\\ \h�--N
CLASS k COUNTY 7:Kc-cs-"�
OPERATOR IN RESPONSIBLE CHARGE (ORC)2hg_�cr%
Qnaj-,_:_ cs— GRADE_ PHONE.Q-kDA)T-VL-qLLA
CERTIFIED LABORATORIES (1)
(2) -
CHECK BOX IF ORC HAS CHANGED F
PERSON(S) COLLECTING SAMPLES._\1-,a
�,=,,-\
Mail ORIGINAL and ONE COPY to:
ATTN: CENTRAL FILES
X �
DIN'. OF ENVIRONMENTAL MANAGEMENT
(SIGN TURF OF OPERATOR IN RESPONSIBLE CHARGE) DATE
DEHNR
BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS
P.O. BOX 29535
ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
RALEIGH, NC'2762"535
50050 00010
004001500601-00310
00610100530 31616 00300 00600 006651
FLOW
ENTER PARANirrER CODE
_, "I
-< i�
_ =
=
tn ABOVE NAME AND L
— UNITS
-iF—F 16
<R
<Z
<
0
5-w
BELOW
iN_F _E1
cr
C)
< 5
0
L)
is. c
x
-Z
0 MG/L
HRS
HRS!
Y/N
MGD
*C
I UNITS
10 uGiL1
MG/L
MG/L
MG/L
#/IOOML
mcn,
1 31
U
1 41
. . ..... . .
6!
71 .
.
. . . . . . . . . . . . . .
v)
10.5
jj
I/
ri
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1,
-1411
15
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... .... .
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. ... .
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.
127]
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. . . . ..... .
281 1
1
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1.291
.301
3-1
0"EP AGE
Zomr.. (-C) i Grai, (G).
NionthiYLimi,
D EM F o rm. 1\6 R -7 (12!9 3)

Facility Status: (Please check one of the following)
All monitoring data and sampling frequencies meet permit requirements
Compliant.
All monitoring data and sampling frequencies do NOT meet permit requirements
Noncompliant
If the facility is noncompliant, please comment on corrective actions being taken in respect to equipment, operation, maintenance, etc.,
and a time table If improvements to be made.
I f
"I certify, under penalty of law, that this document and all attachments were prepared under my direction or supervision in accordance
with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my
inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the
information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant
penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
Permittee (Please prin�gr
rr..) q
..aVV V J , C �
Signature 6'f Permittee** Date
Permitter. Address
I5)
Phone Number
L�
Permit Exp. Date
PARAMETER CODES
00010 Temperature
00556
Oil & Grease 00951 Total Fluoride
01067 Nickel
50060 Total
00076 Turbidity
00600
Total Nitrogen 01002 Total Arsenic
01077 Silver
Residual
00080 Color (Pt -Co).
00610
Ammonia Nitrogen
01092 Zinc
Chlorine
00082 Color (ADMI)
00625
Total Kjeldhal 01027 Cadmium
01105 Aluminum
Nitrogen -
00095 Conductivity
00630
Nitrates/Nitrites 01032 Hexavalent Chromium
01147 Total Selenium
71880 Formaldehyde
00300 Dissolved Oxygen
01034 Chromium
31616 Fecal Coliform
71900 Mercury
00310 BOD5
00665
Total Phosphorous
32730 Total Phenolics
81551 Xylene
00340 COD
00720
Cyanide 01037 Total Cobalt
34235 Benzene
00400 pH
00745
Total Sulfide 01042 Copper
34481 Toluene
00530 Total Suspended
00927
Total.Magnesium
.38260 MBAS
Residue
00929
Total Sodium 010,'.5 Iron
39516 PCBs
00545 Settleable Matter
00940
Total Chloride 01051 Lead
50050 Flow
Parameter Code assistant -. may obtained by calling the Water Quality Compliance Group at [phone], extension 581 or 534.
T-ne monthly average for fecal colifotm is to be reported as a GEOMETRIC mean. Use only units designated in tht rep
orsng
facility's permit for reporting data.
* ORC must visit facility and document visitation of facility as required per 15A NCAC 8A .0202 (o) (5.) (B).
** If signed by other thar the peZnittee, delegation of signatory authority must be on file with the state Per 15A NCAC 2B .0506 (o )
(2) (D)

Fast Track Worksheet
Case Number 03 118
Facility Name IHill Haven Residential Care
Permit Number INCO045012
Previous Case Statutory Maximun $25,000
in the Last Iyes per violation
two years
Number of Assessments for previous 6 DMRs Total Assessment Factor =
• 1 O 20 03 0 40 O 6 1.00
1.00
Total
Number Number Penalty/ Assessment
Violations Assessed Parameter Violation Violation Factor Total Penalty
1 1 Fecal Coliform I Weekly avg/daily $250 1 $250.00
max
I
Comments
Prepared by Richard Bridgeman
Grand Total Penalty $250.00 I
Percent of the Maximum Penalty 1.00
Authorized by G.S. 143-215.6A.

Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
Print your name and address on the reverse
so that we can return the card to you.
Attach this card to the back of the mailpiece,
or on the front if space permits. -
Article Addressed to:
MR TOM KINCAID, ADMINISTRATOR
1-nL MAVEN RESIDENTIAL CARE
114 HILL HAVEN RD
STATESVILLE NC 25677
1,wa/rmb/2/12/03
7001 2510 0005 0287 8569
D. Is delivery address different from
If YES, enter delivery address b
❑ Agent
❑ Addressee
C. Date of Delivery
I-) --(3
1? ❑ Yes
❑ No
Service Type
Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
'S, Form 3811 August 2001 i i ` Domestic Return Receipt 102595-01-M-25(

UNITED STATES POSTAL SERVICE
First -Class Mail
PostaGe & Fees Paid
USPS
Permit No. G-10
" Sender: Please print your name, address, and ZIP+4 in this boxy
rr
WATER QUALITY SECTIC
919 NORTH MAIN STREET
.
MOORESVII-LE NC 28115 C
.sue
`
ko
i it i it ii i i i i ii i i i i i i i
'- Iii?i.... ??..i??... ??:?i?i...:?::?i....?
9
n
y+
4

Michael F. Easley, Governor
- William G. Ross Jr., Secretary
Department of Environment and Natural Resources .
Alan W. I(limek, P.E., Director
Division of Water Quality
November 19, 2002 Ar . ;'.. t ?f:,>• . i;.;
CERTIFIED MAIL 70001530 0002 2100 4889
RETURN RECEIPT REQUESTED DEC Q 4 2002
MEMORANDUM
TO: Pamela Edwards eff• ..' '{" y r't'3+
. tJ1: 9"Doi�a:3y �<�ilsa5 '+. dha `dI gVaii{ --._..
FROM: Bob Sledge, Environmental Specialist
Division of Water Quality
SUBJECT: Civil Penalty Assessment Against Hill Haven Residential Care, Inc. =
Within this envelope, please find a civil penalty assessment document that addresses
violations of Hill Haven Residential Care's NPDES (wastewater discharge) permit. This
document was originally mailed to you at the 114 Hill Haven Road address, but it was returned
to us as unclaimed.
If you have any questions about this "Matter, please contact me at [phone],
extension 547.
attachment
cc: _o- gl f ., - - =tc
a Point Source Enforcement File
Central Files
Customer Service Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617
1 800 623-7748 [phone]

"Michael F. Easley, Governor V
William G. Ross Jr., Secretary
Department of Environment and Natural Resources
Alan W. Igimek, P.E., Director
Division of Water Quality
^ � September 25, 2002
P!AL OFFICE
CERTIFIED MAIL 70001530 0002 2100 4551 -
RETURN RECEIPT REQUESTED
Ms. Pamela Edwards
OCT ©a 2002
Hill Haven Residential Care, Inc.
114 Hill Haven Road
Statesville, NC 28677
SUBJECT: Assessment of Civil Penalties for Violations of
G. S-. 143-215.1(a) & NPDES Permit NC0045012.
Hill Haven Residential Care, Inc.
NPDES Permit Number NCO045012
Case Number MV 02-003
Iredell County
Dear Ms. Edwards:
This letter transmits notice of a civil penalty assessed against Hill Haven Residential
Care, Inc. in the amount of $769.00, including $294.00 in enforcement costs.
Attached is a copy of the assessment document explaining this penalty. This action was
taken under the authority vested in me pursuant to delegation provided by the Secretary of the
Department of Environment and Natural Resources. Any continuing violation(s) may be the
subject of a new enforcement action, including an additional penalty.
Within thirty days of receipt of this notice, you must do one of the following:
1. Submit payment of the penalty:
Payment should be made directly to the order of the Department of Environment
and Natural Resources (do not include waiver form). Payment of the penalty will
not foreclose further enforcement action for any continuing or new violation(s).
Please submit payment to the attention of -
Point Source Compliance/Enforcement Unit
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
OR
Customer Service Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617,
1 800 623-7748 [phone]

2. Submit a written request for remission or mitigation including a detailed
justification for such request.
A request for remission or mitigation is limited to consideration of the
reasonableness of the amount of the penalty and is not the proper procedure for
contesting the accuracy of any of the statements contained in the assessment letter.
Because a remission request forecloses the option of an administrative hearing,
such a request must be accompanied by a waiver of your right to an administrative
hearing and a stipulation that there are no factual or legal issues in dispute. You
must execute and return to this office the attached waiver and stipulation form and
a detailed statement which you believe establishes whether:
(a) one or more of the civil penalty assessment factors in G.S. 143B-282.1(b)
were wrongfully applied to the detriment of the petitioner;
(b) the violator promptly abated continuing environmental damage resulting
from the violation;
(c) the violation was inadvertent or a result of an accident;
(d) the violator had been assessed civil penalties for any previous violations;
(e) payment of the civil penalty will prevent payment for the remaining
necessary remedial actions.
Please submit this information to the attention of:
Ms. Coleen Sullins
Water Quality Section Chief
Division of Water Quality
1617 Mail Service Center
Raleigh, North Carolina\ 27699-1617
Please note that all information presented in support of a request for remission
must be submitted in writing. The Director of the Division of Water Quality will
review the information during a bimonthly enforcement conference and inform
you of his decision in the matter of the remission request. His response will
provide details regarding case status, directions for payment and provision for
further appeal of the penalty to the Environmental Management Commission's
Committee on Civil Penalty Remissions. Please be advised that the Committee
cannot consider information that was not part of the original remission request
considered by the Director and therefore, it is very important that you prepare a
complete and thorough statement in support of your request for remission.
or

a
3. Submit a written request for an administrative hearing:
If you wish to contest any statement in this assessment letter, you must request an
administrative hearing. This request must be in the form of a written petition to the
Office of Administrative Hearings and must conform to Chapter 150B of the North
Carolina General Statutes. You must
File your original petition with the
Office of Administrative Hearings
6714 Mail Service Center
Raleigh, North Carolina 27699-6714
and
Mail or hand -deliver a copy of the petition to
Mr. Dan Oakley
General Counsel
Department of Environment and Natural Resources
1601 Mail Service Center
Raleigh, North Carolina 27699-1601
Please indicate the case number (as found on page one of this letter) on the petition.
Failure to exercise one of the options above within thirty days as evidenced by a date
stamp (not a postmark) indicating when we received your response, will result in this matter
being referred to the Attorney General's Office with a request to initiate a civil action to collect
the penalty. Please be advised that additional assessments may be levied for violations that occur
after the review period of this assessment.
If you have any questions concerning this matter, please contact Mr. Bob Sledge at (919)
733-5083, extension 547.
Attachment
cc: Regiohal.Supervisor w/attachments
Compliance/Enforcement File w/attachments
Central Files w/attachments
Sincerely,
Alan W. Klimek, P.E.

STATE OF NORTH CAROLINA NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
COUNTY OF IREDELL File No. MV 02-003
IN THE MATTER OF: )
HILL HAVEN RESIDENTIAL )
CARE, INC. )
FOR VIOLATIONS OF: )
NPDES PERMIT NO. NCO045012 )
AND NORTH CAROLINA GENERAL )
STATUTE 143-215.1(a) )
FINDINGS AND DECISIONS
AND ASSESSMENT OF
CIVIL PENALTIES
Acting pursuant to delegation provided by the Secretary of the Department of Environment
and Natural Resources, I, Alan W. Klimek, P.E., Director of the Division of Water Quality (DWQ),
make the following:
I. FINDINGS OF FACT:
A. Hill Haven Residential Care, Inc..(HHRC) is a corporation organized and existing
under the laws of the State of North Carolina.
B. HHRC operates a 0.018 MGD wastewater treatment plant in Iredell County, which
discharges treated wastewater to anunnamed tributary to Third Creek in the Yadkin -
Pee Dee River Basin.
C. HHRC was issued NPDES Permit No. NCO045012 on January 25, 2000, effective
March 1, 2000, with an expiration date of July 31, 2004. A permit modification was
issued by DWQ on April 2, 2001 regarding a change of the sample frequency for
effluent temperature from daily to weekly. The expiration date remained unchanged.
D. Said permit contains the following relevant monitoring requirements:
Sample
Parameter
Monitoring Requirement
Location
Flow
weekly
I or E
BOD
2/month
E
TSR
2/month
E
Ammonia
2/month
E
Fecal Coliform
2/month
E
TRC
2/week
E
TN
quarterly
E
TP
quarterly
E
BOD - Biochemical Oxygen Demand TSR - Total Suspended Residue
TRC - Total Residual Chlorine TN - Total Nitrogen TP - Total Phosphorus
E - Effluent I - Influent

Hill Haven Residential Care, Inc.
Findings and Decisions
Page Two
E. HHRC's self -monitoring reports for the months of April 2001 through March 2002
revealed the following violations of the above -cited permit monitoring requirements:
(See Attachment A)
F. HHRC's prior record of compliance with programs over which the Environmental
Management Commission has regulatory authority is as follows:
No civil penalties have been assessed within the previous five years.
G. The costs to the State of the investigation and enforcement procedures in this matter
totaled $294.00.
Based upon the above Findings of Fact, I make the following:
II. CONCLUSIONS OF LAW:
A. HHRC is a "person" within the meaning of G.S. 143-215.6A pursuant to G.S. 143-
212(4).
B. NPDES Permit No. NCO045012 is required by G.S. 143-215.1.
C. The monitoring requirements contained in the subject permit are terms, conditions,
or requirements of said permit.
D. HHRC violated G.S. 143-215.1(a) and NPDES Permit No. NCO045012 on five (5)
occasions during the months of April 2001 through March 2002, in the manner and
to the extent described in Attachment A, by failing to monitor the effluent for Total
Residual Chlorine.
E. HHRC violated G.S. 143-215.1(a) and NPDES Permit No. NCO045012 on one
(1) occasion for the week of October 21, 2001 through October 27, 2001, in the
manner and to the extent described in Attachment A, by failing to monitor the influent
or effluent for Flow.
F. HHRC violated G.S. 143-215.1(a) and NPDES Permit No. NCO045012 on one
(1) occasion during the month of October 2001, in the manner and to the extent
described in Attachment A, by failing to monitor the effluent for Biochemical Oxygen
Demand.
G. HHRC violated G.S. 143-215.1(a) and NPDES Permit No. NCO045012 on one
(1) occasion during the month of October 2001, in the manner and to the extent
described in Attachment A, by failing to monitor the effluent for Total Suspended
Residue.

Hill Haven Residential Care, Inc.
Findings and Decisions
Page Three
H. HHRC violated G.S. 143-215.1(a) and NPDES Permit No. NC0045012 on one
(1) occasion during the month of October 2001, in the manner and to the extent
described in Attachment A, by failing to monitor the effluent for Ammonia.
I. HHRC violated G.S. 143-215.1(a) and NPDES Permit No. NC0045012 on one
(1) occasion during the month of October 2001, in the manner and to the extent
described in Attachment A, by failing to monitor the effluent for Fecal Coliform.
J. HHRC -violated G.S. 143-215.1(a) and NPDES Permit No. NC0045012 on one
(1) occasion for the third quarter of 2001, in the manner and to the extent described
in Attachment A, by failing to monitor the effluent for Total Nitrogen.
K. HHRC violated G.S. 143-215.1(a) and NPDES Permit No. NC0045012 on one
(1) occasion for the third quarter of 2001, in the manner and to the extent described
in Attachment A, by failing to monitor the effluent for Total Phosphorus.
L. HHRC violated G.S. 143-215.1(a) and NPDES Permit No. NC0045012 on one
(1) occasion for the fourth quarter of 2001, in the manner and to the extent described
in Attachment A,,by failing to monitor the effluent for Total Nitrogen.
M. HHRC violated G.S. 143-215.1(a) and NPDES Permit No. NC0045012 on one
(1) occasion for the fourth quarter of 2001, in the manner and to the extent described
in Attachment A, by failing to monitor the effluent for Total Phosphorus.
N. A civil penalty may be assessed in accordance with the maximums established by
G.S. 143-215.6A(a) (2).
O. The State's enforcement costs in this matter may be assessed against Hill Haven
Residential Care, Inc. pursuant to G.S.143-215.3(a)(9) and G.S. 143B-282.1(b)(8).
P. The Director of the Division of Water Quality, pursuant to delegation provided by
the Secretary of the Department of Environment and Natural Resources, has the
authority to assess civil penalties in this matter.
Based upon. the above Findings of Fact and Conclusions of Law, I make the following:
III. DECISION:
Accordingly, Hill Haven Residential Care, Inc. is hereby assessed a civil penalty of:
$ a O° For s of five (5) failures to monitor for effluent Total Residual
Chlorine in violation of G.S. 143-215.1(a) and NPDES Permit No.
NC0045012 for the months of April 2001 through March 2002.

Hill Haven Residential Care, Inc.
Findings and Decisions
Page Four
$ 5 o- 0'0 For 1 of one (1) failure to monitor for influent or effluent Flow
in violation of G.S. 143-215. 1 (a) and NPDES Permit No. NCO045012
for the week of October 21, 2001 through October 27, 2001.
$ So. °o For I_ of one (1) failure to monitor for effluent Biological
Oxygen Demand in violation of G.S. 143-215.1(a) and NPDES
Permit No. NCO045012 for the month of October 2001.
$ S Q . n ° For I of one (1) failure to monitor for effluent Total Suspended
Residue in violation of G. S. 143-215.1 (a)(6) and NPDES Permit No.
NCO045012 for the month of October 2001.
$ 5 O. o o For I_ of one (1) failure to monitor for effluent Ammonia in
violation of G.S. 143-215.1(a) and NPDES Permit No. NCO045012
for the month of October 2001.
$ S O - o O For I of one (1) failure to monitor for effluent Fecal Coliform
in violation of G. S. 143-215. 1 (a) and NPDES Permit No. NCO045012
for the month of October 2001.
$ o� ,5 • o
For of one (1) failure to monitor for effluent Total Nitrogen
,in violation of G.S. 143-215.1 (a) and NPDES Permit No. NCO045012
for the third quarter of 2001.
$
For I of one (1) failure to monitor for effluent Total
Phosphorus in violation of G.S. 143-215.1 (a) and NPDES Permit No.
NCO045012 for the third quarter of 2001.
oo
$
For of one (1) failure to monitor for effluent Total Nitrogen
in violation of G.S. 143-215.1 (a) and NPDES Permit No. NCO045012
for the fourth quarter of 2001.
00
$ c� s
For of one (1) failure to monitor for effluent Total
Phosphorus in violation of G.S. 143-215.1 (a) and NPDES Permit No.
NCO045012 for the fourth quarter of 2001.
$ 15 • ° ° TOTAL CIVIL PENALTY
$ 294.00 1 Enforcement costs.
$ -] 0 9. 0 0 TOTAL AMOUNT DUE

Hill Haven Residential Care, Inc.
Findings and Decisions
Page Five
Pursuant to G.S. 143-215.6A(c), in determining the amount of the penalty I have taken into
account the Findings of Fact and Conclusions of Law and the factors set forth in G.S. 143B-282. I (b),
which are:
(1) The degree and extent of harm to the natural resources of the State, to the public health, or
to private property resulting from the violations;
(2) The duration and gravity of the violations;
(3) The effect on ground or surface water quantity or quality or on air quality;
(4) The cost of rectifying the damage;
(5) The amount of money saved by noncompliance;
(6) Whether the violations were committed willfully or intentionally; J
(7) The prior record of the violator in complying or failing to comply with programs over which
the Environmental Management Commission has regulatory authority; and
(8) The cost to the State of the enforcement procedures.
J
(Date) Alan W. imek, P.E., Directo
Division of Water Quality , 6

ATTACHMENT A
Hill Haven Residential Care, Inc.
NPDES Number NC0045012
Monitoring Violations
Monitoring Sample
Number of
Parameter
Week
Frequency Location.
Violations
Flow
10/21-10/27/01
weekly I or E
1
TRC
10/21-10/27/01
; 2/w E ,
1
TRC
1/6-1/12/02
2/w E
1
TRC
1/13-1/19/02
2/w E
1
TRC
1/20-1/26/02
2/w E
1
TRC
1/27-2/2/02
2/w E
1
Monitoring Sample Number of
Parameter
Week/Month
Frequency
Location_
Violations
BOD
October 2001
2/m
E
1
Ammonia
October 2001
2/m
E
1
TSR
October 2001
2/m
E
1
Fecal Coliform
October 2001
2/m
E
1
TN
7/01- 9/01
Quarterly
E
1
TP
7/01 - 9/01
Quarterly
E
1
TN
10/01 - 12/01
Quarterly
E
1
TP
10/01 - 12/01
Quarterly
E
1
BOD - Biochemical Oxgyen Demand
TRC - Total Residual Chlorine
TP - Total Phosphorus
E - Effluent
TSR - Total Suspended Residue
TN - Total Nitrogen
I - Influent

STATE OF NORTH CAROLINA
COUNTY OF STANLY
IN THE MATTER OF ASSESSMENT
OF CIVIL PENALTIES AGAINST
HILL HAVEN RESIDENTIAL CARE, INC.
PERMIT NUMBER NCO045012
s
DEPARTMENT OF ENVIRONMENT C.
AND NATURAL RESOURCES
WAIVER OF RIGHT TO AN
ADMINISTRATIVE HEARING AND
STIPULATION OF FACTS -
FILE NO.(MV 02-003
Having been assessed civil penalties totaling $769.00 for violation(s) as set forth in the
assessment document of the Director of the Division of Water, Quality dated September 23.2002, the
undersigned, desiring to seek remission of the civil penalties, does hereby waive the right to an
administrative hearing in the above -stated matter and does stipulate that the facts are as alleged in the
assessment document. The undersigned further understands that all evidence presented in support of
remission of this civil penalty must be submitted to the Director of the Division of Water Quality
within 30 days of receipt of the notice.of assessment. No new evidence in support of a remission
request will be allowed after'30 days from the receipt of the notice of assessment.
This the day of , 200_
BY
ADDRESS
TELEPHONE

�l✓
DIVISION OF WATER QUALITY
July 31, 2002
MEMORANDUM -TO: Shannon Langley
nr l
FROM: Rex Gleason (�
PREPARED BY: Wes Bell U'
SUBJECT: Fast Track Enforcement (MV)
Violation of NCGS 143-215.1(a) and
NPDES Permit No. NC0045012
Hill Haven Residential Care WWTP
Iredell County, N.C.
Attached is an enforcement report which details violations of NPDES Permit No.
NCO045012 and NCGS 143-215.1(a). Also enclosed is the Hill Haven Residential Care's,
response letter to the Notice of Recommendation for Enforcement. Based upon our review of the
response, an enforcement action is still recommended.
If you have questions or require additional information, please contact Wes or me.
Attachments

STATE OF NORTH CAROLINA
COUNTY OF IREDELL
IN THE MATTER OF:
HILL HAVEN RESIDENTIAL
CARE, INC.
FOR VIOLATIONS OF:
NPDES PERMIT NO. NC0045012
AND NORTH CAROLINA GENERAL
STATUTE 143-215.1(a)
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
File No. MV
FINDINGS AND DECISIONS
AND ASSESSMENT OF
CIVIL PENALTIES
Acting pursuant to delegation provided by the Secretary of the Department of Environment
and Natural Resources, I, Alan W. Klimek, P.E., Director of the Division of Water Quality (DWQ),
make the following:
I. FINDINGS OF FACT:
A. Hill Haven Residential Care, Inc. (HHRC) operates a 0.018 MGD wastewater
treatment plant in Iredell County, which discharges treated wastewater to an unnamed
tributary to Third Creek in the Yadkin -Pee Dee River Basin.
B. HHRC was issued NPDES Permit No. NC0045012 on January 25, 2000, effective
March 1, 2000, with an expiration date of July 31, 2004. A permit modification was
issued by DWQ on April 2, 2001 regarding a change of the sample frequency for
effluent temperature from daily to weekly. The expiration date remained unchanged.
C. Said permit contains the following relevant monitoring requirements:
Sample
Parameter
Monitoring Requirement
Location
Flow
weekly
I or E
BOD
2/month
E
TSR
2/month
E
Ammonia
2/month
E
Fecal Coliform
2/month
E
TRC
2/week
E
TN
quarterly
E
TP
quarterly
E
BOD - Biochemical Oxygen Demand TSR - Total Suspended Residue
TRC - Total Residual Chlorine TN - Total Nitrogen TP - Total Phosphorus
E - Effluent I - Influent

Hill Haven Residential Care, Inc.
Findings and Decisions
Page Two
D. HHRC's self -monitoring reports for the months of April 2001 through March 2002
revealed the following violations of the above -cited permit monitoring requirements:
(See Attachment A)
E. HHRC's prior record of compliance with programs over which the Environmental
Management Commission has regulatory authority is as follows:
No civil penalties have been assessed within the previous five years.
F. The costs to the State of the investigation and enforcement procedures in this matter
totaled $294.00.
Based upon the above Findings of Fact, I make the following:
II. CONCLUSIONS OF LAW:
A. HHRC is a "person" within the meaning of G.S. 143-215.6A pursuant to G.S. 143-
212(4).
B. NPDES Permit No. NCO045012 is required by G.S. 143-215.1.
C. The monitoring requirements contained in the subject permit are terms, conditions,
or requirements of said permit.
D. HHRC violated G.S. 143-215.1(a) and NPDES Permit No. NCO045012 on five (5)
occasions during the months of April 2001 through March 2002, in the manner and
to the extent described in Attachment A, by failing to monitor the effluent for Total
Residual Chlorine.
E. HHRC violated G.S. 143-215.1(a) and NPDES Permit No. NCO045012 on one
(1) occasion for the week of October 21, 2001 through October 27, 2001, in the
manner and to the extent described in Attachment A, by failing to monitor the influent
or effluent for Flow.
F. HHRC violated G.S. 143-215.1(a) and NPDES Permit No.'NCO045012 on one
(1) occasion during the month of October 2001, in the manner and to the extent
described in Attachment A, by failing to monitor the effluent for Biochemical Oxygen
Demand.
G. HHRC violated G.S.. 143-215.1(a) and NPDES Permit No. NCO045012 on one
(1) occasion during the month of October 2001, in the manner and to the extent
described in Attachment A, by failing to monitor the effluent for Total Suspended
Residue.

Hill Haven Residential Care, Inc.
Findings and Decisions
Page Three
H. HHRC violated G.S. 143-215.1(a) and NPDES Permit No. NC0045012 on one
(1) occasion during the month of October 2001, in the manner and to the extent
described in Attachment A, by failing to monitor the effluent for Ammonia.
HHRC violated G.S. 143-215.1(a) and NPDES Permit No. NC0045012 on one
(1) occasion during the month'of October 2001, in the manner and to the extent
described in Attachment A, by failing to monitor the effluent for Fecal Coliform.
J. HHRC violated G.S. 143-215.1(a) and NPDES Permit No. NC0045012 on one
(1) occasion for the third quarter of 2001, in the manner and to the extent described
in Attachment A, by failing to monitor the effluent for Total Nitrogen.
K. HHRC violated G.S. 143-215.1(a) and NPDES Permit No. NC0045012 on one
(1) occasion for the third quarter of 2001, in.the manner and to the extent described
in Attachment A, by failing to monitor the effluent for Total Phosphorus.
L. HHRC violated G.S. 143-215.1(a) and NPDES Permit No. NC0045012 on one
(1) occasion for the fourth quarter of 2001, in the manner and to the extent described
in Attachment A, by failing to monitor the effluent for Total Nitrogen.
M. HHRC violated G.S. 143-215.1(a) and NPDES Permit No. NC0045012 on one
(1) occasion for the fourth quarter of 2001, in the manner and to the extent described
in Attachment A, by failing to monitor the effluent for Total Phosphorus.
N. A civil penalty may be assessed in accordance with the maximums established by
G.S. 143-215.6A(a) (2).
O. The State's enforcement costs in this matter may be assessed against Hill Haven
Residential Care, Inc. pursuant to G.S. 143-215.3(a)(9) and G.S. 143B-282.1(b)(8).
P. The Director of the Division of Water Quality, pursuant to delegation provided by the
Secretary of the Department of Environment and Natural Resources, has the authority
to assess civil penalties in this matter.
Based upon the above Findings of Fact and Conclusions of Law, I make the following:
III. DECISION:
Accordingly, Hill Haven Residential Care, Inc. is hereby assessed a civil penalty of:
$ For of five (5) failures to monitor for effluent Total Residual
Chlorine in violation of G.S. 143-215.1(a) and NPDES Permit No.
NC0045012 for the months of April 2001 through March 2002.

Bill Haven Residential Care, Inc.
Findings and Decisions
Page Four
$ For of one (1) failure to monitor for influent or effluent Flow
in violation of G.S. 143-215.1 (a) and NPDES Permit No. NCO045012
for the week of October 21, 2001 through October 27, 2001.
$ For of one (1) failure to monitor for effluent Biological
tn
Oxygen Demand in violation of G.S. 143-215.1(a) and NPDES
Permit No. NCO045012 for the month of October 2001.
$ For of one (1) failure to monitor for effluent Total Suspended
Residue in violation of G.S. 143-215. 1 (a)(6) and NPDES Permit No.
NCO045012 for the month of October 2001.
$ For of one (1) failure to monitor for effluent Ammonia in
violation of G.S. 143-215.1(a) and NPDES Permit No. NCO045012
for the month of October 2001.
$ For of one (1) failure to monitor for effluent Fecal Coliform
in violation of G.S. 143-215.1(a) and NPDES Permit No. NCO045012
for the month of October 2001.
$ For of two (2) failures to monitor for effluent Total Nitrogen
in violation of G.S. 143-215.1(a) and NPDES Permit No. NCO045012
for the third and fourth quarters of 2001.
$ For of two (2) failures to monitor for effluent Total
Phosphorus in violation of G.S. 143-215.1(a) and NPDES Permit No.
NCO045012 for the third and fourth quarters of 2001.
$ TOTAL CIVIL PENALTY
$ 294.00 Enforcement costs.
$ TOTAL AMOUNT DUE
Pursuant to G.S.• 143-215.6A(c), in determining the amount of the penalty I have taken into
account the Findings of Fact and Conclusions of Law and the factors set forth in G.S. 143B-282.1(b),
which are:
(1) The degree and extent of harm to the natural resources of the State, to the public health, or
to private property resulting from the violations;
(2) The duration and gravity of the violations;
(3) The effect on ground or surface water quantity or quality or on air quality;
(4) The cost of rectifying the damage;

Hill Haven Residential Care, Inc.
Findings and Decisions
Page Five
Pursuant to G.S. 143-215.6A(c), in determining the amount of the penalty I have taken into
account the Findings of Fact and Conclusions of Law and the factors set forth in G.S. 143B-282.1(b),
which are:
(1) The degree and extent of harm to the natural resources of the State, to the public health, or
to private property resulting from the violations;
(2) The duration and gravity of the violations;
(3) The effect on ground or surface water quantity or quality or on air quality;
(4) The cost of rectifying the damage;
(5) The .amount of money saved by noncompliance;
(6) Whether the violations were committed willfully or intentionally;
(7) The prior record of the violator in complying or failing to comply with programs over which
the Environmental Management Commission has regulatory authority; and
(8) The cost to the State of the enforcement procedures.
(Date) Alan W. Klimeck, P.E., Director
Division of Water Quality

ATTACHMENT A
Hill Haven Residential Care, Inc.
NPDES Number NC0045012
Monitoring Violations
Monitoring Sample
Number of
Parameter
Week
Frequency Location
Violations
Flow
10/21-10/27/01
weekly I or E
1
TRC
10/21-10/27/01
2/w E
1
TRC
1/6-1/12/02
2/w E
I
TRC
1/13-1/19/02
2/w E
1
TRC
1 /20-1 /26/02
2/w E
1
TRC
1 /27-2/2/02
2/w E
1
Monitoring Sample Number of
Parameter.
Week/Month
Frequency
Location
Violations
BOD
October 2001
2/m
E
1
Ammonia
October 2001
2/m
E
1
TSR
October.2001
2/m
E
1
Fecal Coliform
October 2001
2/m
E
1
TN
7/01 - 9/01
Quarterly
E
1
TP.
7/01 - 9/01
Quarterly
E
1
TN
10/01 - 12/01
Quarterly
E
1
TP
10/01 - 12/01
Quarterly
E
1
BOD - Biochemical Oxgyen.Demand
TSR - Total Suspended Residue
TRC - Total Residual Chlorine
TN - Total Nitrogen
TP - Total Phosphorus
I - Influent
E - Effluent

DIVISION OF WATER QUALITY
ENFORCEMENT CASE ASSESSMENT FACTORS
Type: (MV) Monitoring Violations
Violator: Hill Haven Residential Care, Inc.
Address: 114 Hill Haven Road
Statesville, North Carolina 28677
Responsible Official: Ms. Pamela Edwards, President
Address: 1116 Dogwood Road
Statesville, North Carolina 28677
Facility: Hill Haven Residential Care WWTP
NPDES Permit No. NCO045012
Regional Office: Mooresville
1. The degree and extent of harm to the natural resources of the State, to the public health, or
to private property resulting from the violations:
No harm has been measured or documented.
2. The duration and gravity of the violations:
The violations occurred during the period from April 2001 through March 2002.
3. The effect on ground or surface water quantity or quality or on air quality:
No adverse effects have been documented.
4. The cost of rectifying the damage:
No environmental damage has been documented.
5. The amount of money saved by noncompliance:
The contract operation firm hired by Hill Haven Residential Care, Inc. pays a contract
laboratory (Statesville Analytical, Inc.) to perform the biochemical oxygen demand (BOD),
total suspended residue (TSR), ammonia, fecal coliform, total nitrogen (TN), and total
phosphorus (TP) analyses. Statesville Analytical charges $18.00 for each BOD analysis,
$12.00 for each TSR analysis, $14.00 for each ammonia analysis, $16.00 for each fecal
coliform analysis, $25.00 for each TN analysis, and $20.00 for each TP analysis. The total
amount of money saved by failing to monitor for BOD, TSR, ammonia, fecal coliform, TN,
and TP according to the NPDES Permit requirements was $105.00 (1 x $18.00 + 1 x $12.00
+ 1 x $14.00 + 1 x $16.00 + 2 x $25.00 + 2 x $20.00 = $150.00).

Hill Haven Residential Care, Inc.
Assessment Factors
Page Two
6. Whether the violations were committed willfully or intentionally:
There is no evidence to suggest that the violations were committed intentionally.
7. The prior record of the violator in complying or failing to comply with programs over which
the Environmental Management Commission has regulatory authority:
No civil penalties were assessed within the previous five years. A Notice of Violation (NOV)
was issued on March 23, 2001 for monitoring violations (162 failures to monitor effluent
temperature). In addition, a Notice of Deficiency (NOD) was issued on May 21, 1999 that
included numerous monitoring violations (14 total including failures to monitor flow, TRC,
BOD,.ammonia, TSR, and fecal coliform). A NOV and Revocation for Non -Payment was
issued on September 28, 1998 for the failure to pay the annual fee within the stipulated time
period. The fee was paid within the extended time period (60 days) specified in the letter.
8.. The cost to the State of the enforcement procedures:
Central Office Review and Processing = $100.00
8.0 hours by investigator for investigating and
drafting report @ $17.3 8/hour = $13 9.04
1.0 hour for Supervisory review @ $39.96/hour = $ 39.96
1.0 hour for clerical support @ $15.00/hour = $ 15.00
TOTAL, = $294.00
9. Type of violator and general nature of business (i.e. individual vs. large corporation):
The violator is a business that operates as a rest home.
10. Violator's degree of cooperation (including efforts to prevent or restore) or recalcitrance:
The violator appears to be cooperative in addressing violations at the facility.
11. Mitigating Circumstances:
None.
12. Assessment Factors:
a. IWC: 8%
b. Receiving Stream: Unnamed tributary to Third Creek
C. SOC/JOC status/negotiations: N/A
d. DMR's: Attached
e. Copy of Limits Page in Permit: Attached
f. Damage: None documented.

CERTIFICATION PAGE
I certify that the information in this report -is true to the best of my
knowledge. All violations of self -monitoring data have been verified by hard copy
review of the monthly reports and the appropriate permit.
Signature of Principle Investigator(s)
Wesley N. Bell
Date: 17 / 3 010

OF W A Fp Michael F. Easley
Governor
h1C i:EPi. Or G. Ross. Jr.. Secretary
NCDENR North Carolin ant (2f:>wii ifr'dWiFzit and Natural Resources
M0C)R_=SVl� Kerr T. Stevens. Director
` = F Division of Water Quality
April 2, 2001 APR 0 9 2001
Ms. Pamela Edwards
Hill Haven Residential Care, Inc.
114 Hill Haven Road
Statesville, North Carolina 28677
Subject: NPDES Permit Modification
Permit NCO045012
Hill Haven %XIVI I'P
Iredell County
Dear Ms. Edwards:
The Division received and reviewed the request submitted by your ORC to modify the subject permit. Vfe have
no objection to his request. This permit modification changes'the sample frequency for temperaturefrom daily to
weelay.
Y�
Pleas-- find enclosed the revised (and reformatted) effluent..page- The'revised:page should be inserted into vour
permit. The old page may then be discarded. All other terms and conditions contained in the original permit remain
unchanged and in full effect. -This permit modification is issued under the requirements of North 'Carolina Genera:
Statutes 145-215.1 and the iNlernorandum of Agreement between North Carolina and the U.S. Environmental
Protection Agency.
If any parts, measurement frequencies or sampling requirements contained in this permit modification are
unacceptable to vou, you have the right to an adjudicatory hearing upon written request within thirty (30) days
ioliowing receipt of this letter. This request must be a written petition conforming to Chapter 150B of the North
Carolina General Statutes, 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.
If you have any questions concernin(- this permit modification, please contact Charles Weaver at (919) ?33-5083,
extension 311.
Sincerely,
�_err T. Stevens
cc: Cenrral Files
Mooresvilie Regional Office, Water Qualit}. Section
Point Source Compliance Enforcement unit
NPDES unit
Overcash Environmental Services
1617 t0all Service Center, Raleigh, North Carolina 27699-1617 Telephone [phone] FAX [phone]
An Equal 0pponunk, Affirmative Action Employer VISIT us ON THE INTERN` r @ http://h2o.enr.state.nc.us/NPDFS

Permit NC00A5012
A. (1.) EFFLUENT LIMITATIONS AND MONITORING REQUIREMENTS
During; the period beginning on the effective date of the permit and lasting; until expiration, the Permittee is authorized to
dischart,c from outfall 001. Such discharges shall be limited and monitored by the Permittee as specified below:'
EFFLUENT CHARACTERISTICS .
;-LIMfiS
MONITORING -REGUIREME.M. ,.::`. =-=
Manthy= =
Rverg9W--
:Daily
�Mazimum
Measurement
Frequency
Sample Type
;SampEe'locaiiori1
_==
Flow
0.018 MGD
Weekly
Instantaneous
Influent or Effluent
80D, 5 day (20°C)
30.0 mg/L
45.0 mg/L
2/Month
Grab
Effluent
Total Suspended Residue
I 30.0 mg/L
45.0 mg/L
2/Month
Grab
Effluent
NH3 as N (April 1 — October 31)
9.4 mg/L
2/Month
Grab
Effluent
NH3 as N (November"l — March 31)
30.0 mg/L
2/Month
Grab
Effluent
Fecal CoNorm (geometric mean)
200/100 ml
400/100 ml
2/Month
Grab
Effluent
Total Residual Chlorine
2/Week
Grab
Effluent
Temperature (°C)
I
Weekly
Grab
Effluent
Total Nitrogen
(NO2+NO3+TKN)
Quarterly
Grab
Effluent
Total Phosphorus
I
Quarterly
Grab
Effluent
pH1
2/Month
Grab
Effluent
Footnotes:
1. The pH shall not be less than 6.0 standard units nor greater than 9.0 standard units.
There shall be no discharge of floating solids or visible foam in other than trace amounts.

Permit NC0045012
STATE OF NORTH CAROLIN A
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.
Hill Haven Residential Care, Inc.
is hcreby authorized to discharge wastewater from a facility° located at
Hill Haven Residential Care
114 Hill Haven Road
Statesville
Iredell County
to receiving waters designated as an unnamed tributary to Third Creek in the Yadkin -Pee Dee River Basin
in accordance with effluent limitations, monitoring requirements. and other conditions set forth. in Parts 1.
Il. III. and IV hereof.
The permit shall become effective March 1, 2000
This permit and the authorization to discharge shall expire at midnight on July 31, 2004
Signed this day January 25, 2000
i1gI,7&i By
D81JiG ��r
.. '_,J3-Ch
Derr T. Stevens. Director
Division of Neater Quality
By Authority of the Environmental Management Commission

n.(I) [;I I 71,LjI NT HMI'I ATIONS AND MONITORING IZl;t1(.IIIZL;�II,NTS Perini( No. NC00-1501 2
During the period beginning on the effective date of the permit and lading until expiration, the herllliltCC is aut11orized to discharge I'rom oul(r111
serial number 001. Such discharges shall be limited and monitored by the Pernniltee as specified below:
EFFLUENT CFIARACTERISTICS
LIMITS
MONITORING REQUIREMENTS
Monthly
Average
Weekly
Average
Daily
Maximum
Measurement
Frequency
Sample
Type
Sample
Locatlon'
Flow
0.018 MGD
Weekly
Instantaneous
I or E
BOD, 5 day, 200C
30.0 m /I
45.0 rng/l
2/Month
Grab
E
Total Suspended Solids
30.0 m /I
45.0 mg/1
2/Month
Grab
E
NH, as N (April 1 to October 31)
9.4 m /1
2/Month
Grab
E
NH, as N (Novernber 1 to March 31)
30.0 m /I
2/Month
Grab
E
Fecal Coliform (geometric mean)
200 / 100 ml
400 / 100 ml
2/Month
Grab
E
Total Residual Chlorine
2/Week
Grab
E
Temperature
Daily
Grab
E
Total Nitrogen (NO, 4- NO, + TKN)
Quarterly
Grab
E
Total Phosphorus
Quarterly _
Grab
E
PI -I'
2/Month
Grab
E
Notes:
' Sample locations: l — lnflucnt, E — Eflliienl.
"The 1AI shall not be less than 6.0 standard units nor -greater than 9.0 standard units.
There shall be no discharge of floating solids or visible foan) in other than trace amounts.

- iT
LWQ
Mr Wes -Bell
919 N Main St.
Mooresville NC 28115
Subject: Responce to notice of violation.
Dear Mr Be] I:
:%user a lent iiy conversation with Steve Overeash it was obvious that we had a serious
communication problem as to exactly what his duties were pertaining to the septic
s,.,stem. W e now have a clear understanding of exactly what is to be done b}- whom.- will
see to it myself that the filter bed stays clean and grass free, and Mr_ Overcash for the
time being will continue to monitor our water as he has been under contract for the last
four vears . I aI)OloE Ze for not monito-gig closer myself ,but certa?nli' intend to do SO in
the future . As far as water quality and sampling I have to depend on Mr. Overcash to
inform. me of any irregularities, thus far he has not mentioned any problem areas. Frank
you for bringing this to my attention and if you have any further questions or comments
please contact me .Please find enclosed photographs of the filter bed area which was
cleaned on 7/10/02 . If you can recommend anyone else who can monitor filter beds
please let me know.
Sincerelv, .
Mr. Tom Kincaid.
JUL 1 5 20V .

a EFFLUENT
NPDES PERMIT NO. NC 0045012 DISCHARGE NO. 001 MONTH FEBRUARY 'YEAR 2002
FACII..ITYNAME HILLHAVEN CLASS I COUNTY IREDELL
OPERATOR IN RESPONSIBLE CHARGE (ORC) RAMON GARCIA GRADE' II PHONE_ [phone]
CERTIFIED LABORATORIES (1) Statesville ABalvdcal (2)
CHECK BOX IF ORC HAS CHANGED ❑ PERSON(S) COLLECTIriG' SAMPLES Ramon Garcia
Mail ORIGINAL and ONE COPY to ` �•
ATIN: CENIR.ALFiIFFS
DIVISION OF WATER QUA=
1617 AU , SERVICE CENTER
(SIGNATURE OF OPERA R IN RESPO IBLE CHARGE) DATE
11RF
RALEIGH. INC 27699-1617 BY THIS SIGNATURE, I CERTIFY THAT THE REPORT IS
ACCURATE AND COMPLETE TO TBE BEST OF MY KNOWLEDGE
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EFF uEWR ��•n•, ��
NPDES PERMIT NO. NC 0045012 DISCHARGE NO. 001 MONTH January YEAR 2002
FACILITY NAME HILLHAVEN CLASS I COUNTY MEDELL
OPERATOR IN RESPONSIBLE CHARGE (ORC) Ramon Garcia GRADE I PHONE [phone]
CERTIFIED LABORATORIES (1) Statesville Analvtical (2)
CHECK BOX IF ORC HAS CHANGED ❑ PERSON(S) COLLECTING SAMPLES Ramon Garcia
Mail ORIGINAL and ONE COPY to:
ATTN: CENTRAL FILES
DIVISION OF WATER QUALITY
16;17 MAIL SERVICE CENTER
RALEIGH_ NC 27699-1617
X
(SIGNATURE OF OPERATOR IN RESPONSIBLE CHARGE)
BY THIS SIGNATURE. I CERTIFY THAT THE REPORT IS
I
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DWQ Form MR-1 (01/00)

EFFLUENT
NL PDES PERMIT NO. NC 0045012 DISCHARGE NO. 001 MONTH December YEAR 2001
FACILITY NAME HILLHAVEN CLASS I COUNTY IREDELL
OPERATOR IN RESPONSIBLE CHARGE (ORC) Ramon Garcia GRADE I PHONE [phone]�8
CERTIFIED LABORATORIES (1) Statesville Analytical (2)
CHECK BOX IF ORC HAS CHANGED ❑ PERSON(S) COLLECTING SAMPLES Ramon Garcia
Mail ORIGINAL and ONE COPY to:
ATTN: CENTRAL FILES
DIVISION OF WATER QUALITY
1617 MAIL SERVICE CENTER
RALEIGH, NC 27699-1617
(SIGNATURE OF OPERATOR IN RESPONSIBLE CHARGE)
BY THIS SIGNATURE, I CERTIFY THAT THE REPORT IS
ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE
1
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121
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I
I
I
I
I
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! NA
131
1
1
1
1I
1
1
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1
1
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I
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I
141 0100
1 0.5'
1 y
INo Flow
II
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I
I
I
I NA
I
I
I I
151
1
1
I
1
I
1
I
1
1
1
1 NA
1
161
1
I
1
1
1
1
I
1
1
1
NA
II
I
I
171
1
I
1
1
1
NA
I
I
i
181
1
I
1
1
1
1
1
I
1
1
I NA
I
I
I
I
1
i
191 0900
I 0.5
I Y
.0008
9.1
I 7.1
.7
11.4
1 9.86
1 12.0
1 40
1 NA
I
201
I
I
I
I
I
I NA
I
I
I
1
211 1110
1 .4
1 Y
I No Flow
I
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NA
I
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1
221
1
1
1
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I
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I
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231
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1
1
1
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I
241 0830
1 1.0
1 Y
1 .001
I 8.9
6.9
I _5
I
NA
251
i
1
1
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I
I NA
261
1
1
I
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I
I NA
271 -
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I
I
281 0945
1 1.0
1 v
1 .0009
1 9.7
I
1 .4
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291
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I
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301
1
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NA
I
I
I
I
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311
1
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I
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AVERAGE
0.002
10.58
INNIM
0.5
13.2
I 8.74
I 14.2
1 6.32
NA
I
I
I
I
I
I
MAXIMUM
0.007
f,6.2
7.1
I 0.7
15
9.86
16.4
I 40
NIDUNfUM
0.001
8.9
I 6.7
0.4
11.4
7.62
I 12
I 1
I I
I
1
Comp. C Grab G
Instant.
G
G
G
G
G
G
G
Monthly Limit
.018
6=9
30
19.4/30-1
30
1 200
1 NA
1
1 I
1
1
*Ap-Oct. 9.4/Nov-Mar 30
DWQ Form MR-1 (01/00)

E 1
NPDES PERMIT NO. NC 0045012 DISCHARGE NO. 001 MONTH November YEAR 2001
FACILITY NAME Hii •T_•HAVEN CLASS I COUNTY IREDELL
OPERATOR IN RESPONSIBLE CHARGE (ORC) Ramon Garcia GRADE I PHONE [phone]
CERTIFIED LABORATORIES (1) StatmgUe-Analytical (2) q
CHECK BOX IF ORC HAS CHANGED PERSON(S) COLLECTING SAMPLES Ram
I ..
Mail
A
DIVISION
16 f7
R+MGH.
ORIGINAL and ONE COPY to: ( C
: CENTRAL FILES X c_----- _ % -
OF WATER QUAI= (SIGNATURE OF OPERATOR IN RESPONSIBLE CHARGE) DATE
MAIL SERVICE CENTER BY Un SIGNATURE, I CERTIFY THAT TBE REPORT IS
NC 27699-1617 ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE
>o
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141
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161
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171
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181
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191
1230 I 2
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I
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201
0900 1 .4
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211
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221
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231
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I 1
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241
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251
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261
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271
1
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I I
281
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I I
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291
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I
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301
1000 1 .2
1 Y
1
19.5
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I
I
NA
I
1
1
31
I
I
I
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NA
AVERAGE
10.001
115.47
0.8
4.0
9.075
5.1
1
NA
I
I 1
I
MAX-UvIUM
1 0.001
1 19.5
6.9
2.5
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11.65
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1
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Iv1NDAUM
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1 14
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2
6.5
1 5
1
Cam . C Grab G
Instant
G
G
G
G
G
G
G
Monthiv Limit
.018
I -
6-9
30
9.4/30*
I 30
1 200
NA
1
1 I
1 1
*Ap-Oct. 9.4/Nov-Mar 30
DWQ Form MR-1 (01/00)

EFFLUENT �Ft° 2 2001
IDES PERMIT NO. NC 0045012 DISCHARGE NO. 001 MONTH Oct YEAR 2001
FACILITY NAME HILL.HAVEN CLASS I COUNTY IREDELL
OPERATOR IN RESPONSIBLE CHARGE (ORC) Jerry Rogers -ROMAN GARICA GRADE II PHONE (704)
878-0114
CERTIFIED LABORATORIES (1) Statesville Analytical (2)
CHECK BOX IF ORC HAS CHANGED 11 PERSON(S) COLLECTING SAMPLES Jerry Rogers
Mail ORIGINAL and ONE COPY to: •
ATM: CENTRAL FILES
DIVISION OF WATER QUALITY
1617 MAIL SERVICE CENTER
RALEIGII. NC 27699-1617
(SIGNATUREJOF OP E TOR ✓RESPONSIBLE CHARGE)
BY THIS SIQVATURE, I CERTIFY THAT THE REPORT IS
ACCURATE.{ND COMPLETE TO THE BEST OF MY KNOWLEDGE _
*Ap-Oct. 9.4/Nov-Mar 30

EFFLI NT Nov 0 7 2001
NPDES PERM[T NO. NC 0045012 DISCHARGE NO. 001 • MONTH SEPTEMBER • - YEAR _001
FACILITY NAME H1I.T.HAVEN CLASS I COUNTY IREDELL
OPERATOR IN RESPONSIBLE CHARGE (ORC) Jerry Rogers GRADE H PHONE [phone]
CERTIFIED LABORATORIES (1) Statesville Analytical (2)
CHECK BOX IF ORC HAS CHANGED ❑ PERSON(S) COLLECTING SAMPLES Jern, Rogers
Mail ORIGINAL and ONE COPY to:
A77N: CENTRAL FILES X
DIVISION OF WATER QUALITY (SIGNATURE
1 k17 VArr- CARvT(`R r-v.vTF.R
DATE.,;
-
RALEIGH,
- -- -- --- -- -- BY TEiS SIGNAIKM4 CERTII'Y THAT THE REPORT 1S y. a
NC 27699-1617 ACCURATE AND COMPLETE TO TEE BEST OF MY KNOWLEDGE �i •,
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311
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G
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G
1
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.018
1 -
6-9
-
30
9.4/30;
30
I 200
NA
*ApOct. 9.4/Nov-Mar 30
DWQ Form MR-1 (01/00)

EFFLUENT
NPDES PERMIT NO. NC 0045012 DISCHARGE NO. 001 MONTH AUGUST YEAR 2001
FACILITY NAME HILLHAVEN CLASS I COUNTY IREDELL
OPERATOR IN RESPONSIBLE CHARGE (ORC) Jerry Rogers GRADE 11 PHONE [phone]
CERTIFIED LABORATORIES (1) StatesviIle Analytical (2)
CHECK BOX IF ORC HAS CHANGED , ❑ PERSON(S) COLLECTING SAMPLES Jerry Rogers -
Mail ORIGINAL and ONE COPY to:
ATTN: CENTRAL FILES
DMSION OF WATER QUALITY
1617 MAIL SERVICE CENTER
RALEIGH, NC 27699-1617
X . I A-6
(SIGNATURfOF OPERATOR IR RESPONSIB CHARGE)
BY THIS SIG A I CERTIFY THAT THE REPORT IS
ACCURATE ANWOOMEPLETE TO THE BEST OF MY KNOWLEDGE
'AP-UCt. YAMOv-Mar 30
DWQ: Form-MR-I'(01/00)
- 2-6 -O
DATE

4-4
EFFLUENT
NP,DES PERMIT NO. NC 0045012 DISCHARGE NO. 001 MONTH JULY YEAR 200 ., :
FACILITYNAME HILLHAVEN —.CLASS I COUNTY IREDELL
OPERATOR IN RESPONSIBLE CHARGE (ORC) Jerry Rogers GRADE II PHONE [phone]
CERTIFIED LABORATORIES (1) Statesville Analytical (2)
CHECK BOX IF ORC HAS CHANGED ❑ PERSON(S) COLLECTING SAMPLES Jerry Rogers
Mail ORIGINAL and ONE COPY to:
A-I-rN: CENTRAL FILES -
D�VISION OF WATER UALITY
1617 MAIL SERVICE
RALEIGI- NC 27699-
.Y
U
U
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O '
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_
U
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cam'
c N
"Q
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^I
c5
O� i
O
Q (SIGNATURE F PERATOR SPONSIBLE C GE) DATE
CENTER BY THIS SIGNA , I CERTIFY THAT THE REPORT IS
1617 ACCURATE AND OMPLETE TO THE BEST OF MY KNOWLEDGE
- 50050 00010 00400 50060 00310 1 00610 1 00530 1 31616 00300 00600
FLOW w
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Ol.......25.4.:,:..::._.7..11072:.;:0:672MMM
:,:,.,:E:<:;;:;
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1 24.7
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I 018
1 -
1 6-9 1
30
1 9AGO*
1
200 .1
NA
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*Ap-Oct. 9.4/Nov-Mar 30
DWQ Form MR-1
(01/00)

File Tasks Queries Administration HelpI
Insert
__..__
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Payment FemisSian Petition C�Ilectiori Settlement. Related Casefi Comments '
•
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`Permit: NC0045012 Deteils:..
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Facility
HiII Haven Residential Care "
Details.:.
Region: Mooresville
County: Iredell
:#
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Marntair :-
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DEtail ..
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Comments:
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CentralOffice.Contact-:Sledge 'RobertL77
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Regional Contact- Bell WesIey N-,
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Enforcement`Contact: P,,amela Edvvards
Salutation for Letter: ; Ms. Edwards
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_PenaltyAssessed Date: 09123/2002 ".
Remission Re"quest:
EMC Hearing Date:
Letter Date:-" 09I M002
Remission Ackriowledged: h_ ": •
Remission Amount:
PenaliyAmount $475.00
Ent Conf Date:.
EMC Results Received:- `
l
`
Damages:' '
Remission Amount:
Enforcement Cost: $294.00
Enf. Conf: Letter Date:
Petition in OAH:. "
}
Total Case Penalty` $769:00 _
Facility Rcvd. Enf- Conf. Ltr.:
Remission Amount:
'
Facility Received F&D. 1.1127/2002
Total Am hfi©ue $0�00
Case to Collection:
Response Due�By: 12I27I2002 `TotalsAmoaPaid:
$�7L69�00,."`Settlement
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n ?SIR TOM KINCAID, ADIVIlNISTRATOR
IML HAVEN RESIDENTIAL CARE, INC
a 114 HILL HAVEN RD
.-------------------
STATESVILLE NC 28677
WQ------------------.

Certified Mail Provides: .
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■ A unique identifier for your mailpiece
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Important Reminders:
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r_ =E=eX tzlovemor
vY r►.t ��QG
� f
June 27, 2002
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
Mr. Tom Kincaid, Administrator
Hill Haven Residential Care, Inc.
114 Hill Haven Road
Statesville, North Carolina 28677
Dear Mr. Kincaid:
William G. Rom jr-. Secyetary
North Carolina Deparment of Environment and t`mum. l Resources
es
Alan W. Klimek. P =-, Director
Division of WMer Quality
`fi ka.nA,<
Subject: Notice of Violation/Notice of
Recommendation for Enforcement
Compliance. Evaluation Inspection
Hill Haven Nursing Home WWTP
NPDES Permit No. NCO045012
Iredell County, NC
Enclosed is a copy of the Compliance Evaluation Inspection Report for the inspection
conducted at the subject facility on June 17, 2002 by Mr. Wes Bell of this Office. Please inform the
facility's Operator in Responsible Charge of our findings by forwarding a copy of the enclosed report
to him.
This report is being issued -as a Notice of Violation (NOV)/Notice of Recommendation for
Enforcement (NRE) because of the facility's failure to properly operate and maintain the WWTP and
the numerous monitoring violations of the subject NPDES Permit and North Carolina General
Statute (G.S.) 143-215.1.as detailed in the Facility -Site Review/Operations &a Maintenance and
Self -Monitoring Sections of the attached report. Pursuant to G.S. 143-215.6A, a civil.penalty of
not more than twenty-five thousand dollars ($25,000.00) per violation, per day may be assessed
against any person who violates or fails to act in accordance with the terms, conditions, or
requirements of any permit issued pursuant to G.S. 143-215.1.
It is requested that a written response be submitted to this Office by July 17, 2002, addressing
the deficiencies noted in - the Facility Site Review/Operations and Maintenance, Flow
Measurement, Laboratory, and -Self -Monitoring Sections of the report. In responding, please
address your comments to the attention of Mr. Richard Bridgeman.
N. C.Division of Water Quality 919 North Main Street, Mooresville NC 28115 Phone (704) 003- ic99
I FAX [phone]

NOV/NR ,
Mr. Tom Kincaid
Page Two
This letter is also to advise you that this Office is considering sending a recommendation for
enforcement action to the Director of the Division of Water Quality for the failure to properly operate
and maintain the WWTP and the monitoring violations of G.S. 143.215.1(a) and the NPDES Permit
No..NC0045012. If you have an explanation for the violations that you wish to present, please
include same in the requested response. Your explanation will be reviewed and if an enforcement
action is still deemed appropriate, your explanation will be forwarded to the Director along with the
enforcement package for his consideration.
The report should be self-explanatory; however, should you have any questions concerning
this report, please do not hesitate to contact Mr. Bell or me at [phone].
Sincerely,
D. Rex Gleason, P.E.
Water Quality Regional Supervisor
Enclosure
cc: Iredell County Health Department
1i1

US Environmental Protection Agency, Washington, D.C., 20460
AA,OMB
Form Approved.
No.2040oos7
" ..A Water Compliance Inspection Report
` NC Division of Water Quality / Mooresville Regional Office NCDE R
Approval Expires 8-31-98
!Section :A:'National Data:System!Coding
Transaction Code . NPDES No. Yr/Mo/Day Inspection Type Inspector Facility Type
N 5 NCO045012 02/06/17 C S 2
Remarks:
Inspection Work Days Facility Evaluation Rating BI QA ..........Reserved...........
1.5 1 N N
Section.B: FacilityData
Name and Location of Facility Inspected:
Entry Time:
Permit Effective Date:
'Hill Haven Residential Care, Inc.
10:13 am
00/03/01
114 Hill Haven Road
Exit Time/Date:
Permit Expiration Date:
Statesville
lredell County, North Carolina
10:33. am
04/07/31
02/06/ 17
Name(s) of On -Site Representative(s)/Title(s)/Phone No(s)/Fax No(s):
Mr. Ramon.Garcia/ORC - Overcash Environmental/704-663-3228
Name and Address of Responsible Official:
Title: Administrator
Mr. Tom Kincaid
Hill Haven Residential Care, Inc.
114 Hill Haven Road
Phone No-
'Contacted?
Statesville, North Carolina.-28677
704-872-7601
No
�Section�C:.Areas Evaluated-.During<Inspection{Checksorily:those:areas•evaluated)
X Permit X Flow Measurement X Operations & Maintenance X Sewer Overflow
X Records/Reports X Self -Monitoring Program X Sludge'Handling/Disposal Pollution Prevention
X -Facility Site Review Compliance Schedules Pretreatment Multimedia
X Effluent/Receiving Waters X Laboratory Storm Water Other:
.Section DrSummary.ofFindings/Comments-
See Attached Sheets) forSummary.
Name(s) and Signature(s)of Inspectors:
Agency/Office/Telephone No:
Date:
Wes Bell. /i2� /%�
NCDWQ/MOORESVILLE/[phone]
6/25/02
Date:
Signature of Management QA Reviewer:
Agency/Office/Phone & Fax No:
Date:
EPA Form 3560-3 (Rev. 9-94) Previous editions are obsolete

Hill Haven WWTP
Page Two
The facility was last inspected by Wes Bell of this office on February 19, 2001.
PERMIT:
The permit authorizes the continued operation of an existing 0.018 MGD wastewater
treatment system consisting of two septic tanks, two surface sandfilters, and effluent chlorination.
The permit for this facility became effective on 3/l/00 and expires on 7/31/04. A permit
modification was issued by the Division on 4/2/01 regarding a change in the sampling frequency for
effluent temperature from daily to weekly.
RECORDS AND REPORTS:
The Operator in Responsible Charge (ORC)/maintenance log and calibration data were
reviewed at the time of the inspection. In addition, the chain of custody forms and laboratory
analyses were reviewed at the certified laboratory contracted to provide analytical support (See Self -
Monitoring Section). The calibration of laboratory instruments was not documented properly (See
Laboratory Section).
FACILITY SITE REVIEW/OPERATIONS & MAINTENANCE:
Only one septic tank and sandfilter are currently being utilized. The facility was not well
maintained at the time of the inspection. The facility had repaired the distribution box and adjacent
wall; however, a leak was observed underneath the patched areas. In addition, abundant vegetation
was observed in the filter bed and one of the laterals was leaking at the wall junction. Solids had not
been removed from the filter bed. The vegetation on the surrounding grounds was dense and not
maintained. The second (unused) filter bed system was in poor condition. The chlorine contact
chamber did not have a cover to prevent the accumulation of sticks, leaves, etc. Please be advised
that the NPDES Permit requires that the facility be properly operated and maintained at all times.
Failure to provide the appropriate operation and maintenance can subject the facility to possible civil
penalties. The ORC indicated that the Hill Haven maintenance personnel are responsible for the
WWTP maintenance.
The facility is staffed with one Grade I ORC. A certified back-up operator has been
designated (Steve Overcash - Overcash Environmental) when the ORC is unable to visit the facility.
Rating: Unsatisfactory (This section is rated unsatisfactory due to the poor operation and
maintenance at this facility)
LABORATORY:
Statesville Analytical (Certification #440) of Statesville, N.C. has been contracted to provide
analytical support. The lab was not evaluated during this inspection.
The TRC meter was in poor condition at the time of the inspection. The meter had been
dropped and the glass cover had been removed. All meters must be properly maintained at all times.
This office recommends the replacement of the TRC meter.

Hill Haven WWTP
Page Three
LABORATORY cont'd:
The annual calibration curve was not available at the time of the inspection. The certified
lab was contacted and the last annual calibration performed on this instrument was February 2000.
In addition, the ORC indicated that a midrange check standard was not utilized/verified during each
day of meter usage. Please be advised that the TRC meter must be calibrated either annually with
five standards, and a verification of a blank and midrange check standard every day the meter is used,
or a verification of a blank and three standards every day the meter is used (Ref: Standard Methods,
18th Edition - Method 1020B Quality Control (5) pages 1-5).
The pH meter appeared to be properly calibrated; however, the value for the check standard
was not documented to ensure the .value is within 0.1 unit of the check standard (Ref: Standard
Methods, 18th Edition -Method 4500-H+ B).
The calibration of the laboratory instruments is poorly documented. The ORC should
develop a separate log that includes the required calibration documentation (for the laboratory
instruments) during each day of usage. In addition, the ORC should view the Division's Laboratory
Certification Unit's website that contains the technical guidance for field parameter testing
(including proper instrument calibration and appropriate documentation) at
www.esb.enr.state.nc:us/lab/field parmguide.htm. Mr. Chet Whiting with the Division's Laboratory
Certification Unit can be contacted at 704-663-1699 ext. 297 for additional guidance.
Rating: Unsatisfactory (This section is rated Unsatisfactory due to the ORC's failure to properly
document and calibrate the laboratory instruments)
EFFLUENT/RECEIVING WATERS:
The effluent discharge was clear with no visible suspended solids or foam. The facility
discharges into an unnamed tributary to Third Creek, which is a Class C water in the Yadkin -Pee
Dee River Basin. The receiving stream did not appear to be negatively impacted. The discharge
outfall was accessible at the time of the inspection.
A review of the DMRs have.indicated numerous TRC values in excess of 28gg/l. Be aware
that a stream action level of 17,ug/1 has been established for total residual chlorine for chronic
toxicity effects. An action level of 28/.cg/1 has been set as the maximum allowable effluent
concentration to protect the receiving stream against acute toxicity effects. Please maintain the total
residual chlorine concentration as low as possible, while still complying with fecal coliform limits.
SELF -MONITORING PROGRAM:
Self -monitoring reports were reviewed for the period April 2001 through March 2002,
inclusive. A fecal coliform violation occurred on l/9/02 (480 colonies/100 mis); however, the value
was incorrectly transcribed as 48 colonies/100 mis.' An amended DMR shall be resubmitted along
with any additional DMRs for inadvertent transcription errors. The following monitoring violations
were noted:
- No effluent total nitrogen and total phosphorus were reported for the third and fourth quarters of
2001.

Bill haven WWTP
Page Four
SELF -MONITORING PROGRAM cont'd:
- Only one BOD, ammonia, total suspended residue, and fecal coliform were reported for October
2001.
- Only one TRC value was reported for the weeks of October 21 through 27, 2001 and January 6
through January 12, January 13 through January 19, January 20 through January 26, and January 27
through February 2, 2002.
- No flow was reported for the week of October 21 through October 27, 2001.
A review of the DMRs with the laboratory analyses indicated an incorrect fecal coliform
value was reported on the November 2001 DMR. The fecal coliform value should have been
reported as <1 colonies/100 mis.; however, 1 colony/100 mis. was reported. A total nitrogen value
was incorrectly calculated on the March 2002 DMR. When values reported as < the method
detection level are reported, then the value shall be considered as zero for calculation purposes. A
resampled fecal coliform value was placed on the incorrect date (reported on 2/21/02 - resampled
on 2/14/02). The ORC and permittee must ensure that all DMRs are accurate and complete before
submittal to the Division.
The effluent sample times were not reported for the on -site parameters performed at the
facility (pH, TRC, and temperature). All data required for sample collection and sample analyses
shall be documented in accordance with Standard Methods, 18th Edition, 1060 B and the NPDES
Permit.
Rating: Unsatisfactory (This section is rated unsatisfactory due to the numerous monitoring
violations)
FLOW MEASUREMENT:
The flow is not being measured according to the permit requirements. Currently, the flow
is being estimated; however, the permit requires instantaneous flow measurements. The facility has
been previously cited for failure to report representative flow data. In addition, the facility has not
incorporated a dose counter measurement system as recommended in previous inspection reports.
Rating: Unsatisfactory (This section is rated unsatisfactory the failure to measure flows according
to the permit requirements)
SLUDGE DISPOSAL:
Septage is removed on an as -needed basis by Lentz Septic Tank Service, Inc. of Statesville,
N.0 and disposed at an approved land application site in Iredell County. .
SEWER OVERFLOW:
Please be advised that pursuant to Part II, Section E of your NPDES permit, and North
Carolina Administrative Code (NCAC) 15A 2B .0506 (a)(2), any failure of a collection system,
pumping station or treatment facility resulting in a bypass without treatment of all or any portion of
the wastewater shall be reported to the central office or the appropriate regional office (Mooresville
Regional Office 704-663-1699) as soon as possible but no later than 24 hours from the time the
permittee became aware of the bypass. Overflows and spills occurring outside normal business hours

Hill Haven WWTP
Page Five
SEWER OVERFLOW cont'd:
may also be reported to the Division's Emergency Response personnel at 800-662-7956, 800-858-
0368, or 919-733-3300. A written report shall also be provided within five (5) days of the time of
the incident. The report shall contain a description of the bypass, and its cause; the period of the
bypass, including exact dates and times, and if the bypass has not been corrected, the anticipated time
it is expected to continue; and steps taken (or planned) to reduce, eliminate, and prevent recurrence
of the similar. events. Any spill that reaches surface waters (i.e. any spill that reaches any water
already present in a conveyance, stream, ditch, etc...) or any spill greater than 1,000 gallons on the
ground that does not reach surface waters must be reported.
An adequate spill response for . those spills reaching surface waters should include an
evaluation downstream of the point at which the spill entered surface waters to determine if a fish
kill occurred. The evaluation should also include the collection of upstream dissolved oxygen and
pH measurements for background information and dissolved oxygen and pH measurements at
multiple points downstream of the entry point to document any negative impact. Failure to report
the bypass of collection system, pumping station or treatment facility subjects violators to penalties
of up to $25,000.00 per day per violation.

Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
Print Vour name and address on the reverse
so that we can return the card to you.
e Attach this card to the back of the mailpiece,
or on the front if space permits.
Article Addressed to:
MR TOM KINCAID, ADMINISTRATOR
HILL HAVEN RESIDENTIAL CARE, INC
114 HILL HAVEN RD
STATESVILLE NC 28677 WQ
I
A.
❑ Agent
❑ Addre
ate of De0
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
Service Type
L Certified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
'fir l 4. Restricted Delivery? (Extra Fee) ❑ Yes
Artid— -- -
1. (rrar 7 _ 25.10 0005 0287 7036
S Form 3811, August 2001 Domestic Return Receipt 102595-01-M-25c

UNITED STATES POSTAL SERVICE
First-Class4Mail
Postage & fees Paid
LISPS
Permit No.-G-10
t.;
• Sender: Please print your name, address; -and ZIP+4 4nthis box •
DENR
WATER QUALITY SECT16'
919 NORTH MAIN STREETf-71
MOORESVILLE NC 28115
11.1 1 1.1d .... HIA'didd

020247084

0314-3034081

DWQ
Mr Wes Bell
919 N Main St.
Mooresville NC 28115
�J
U"
0
Dear Mr Bell:
Subject: Responce to notice of violation.
\�I1ZJ,
0 0
A Ler a ieiig+Lily conLversation with Steve Overcash it was obvious that we had a serious
communication problem as to exactly what his duties were pertaining to the septic
system. We now have a clear understanding of exactly what is to be done by whom.I will
see to it myself that the filter bed stays clean and grass free , and Mr, Overcash for the
time being will continue to monitor our water as he has been under contract for the last
four years . I apologize for not monitoring closer myself , but certainly intend to do so in
the future. As far as water quality, and sampling I have to depend on Mr, Overcash to
inform me of any irregularities, thus far he has not mentioned any problem areas. Thank
...you for bringing this to my attention and if you have any further questions or comments
please contact me .Please find enclosed photographs of the filter bed area which was
cleaned on 7/10/02 . If you can recommend anyone else who can monitor filter beds
please let me know.
Sincerely ,
Mr. Tom Kincaid.
r
jr�
NC DEPT. OF ENVIRONMENT
UOORESVILLEP53iONAI,!°;= I
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