NCG551106_Compliance Evaluation Inspection_20210726

United States Environmental Protection Agency
E PA Washington, D.C. 20460
Water Compliance Inspection Report
Form Approved.
OMB No. 2040-0057
Approval expires 8-31-98
Section A: National Data System Coding (i.e., PCS)
Transaction
1 IN
Code
I 2
IL
NPDES yr/mo/day Inspection Type Inspector Fac
I 3 I NCG551106 111 121 21/07/26 117 1810I 19I S I 2011
Type
21IIIIII
IIIIIIIIIII
IIIIIII
I
IIIIII
IIIIIIIIIII
P6
Inspection
671
Work Days
Facility Self -Monitoring
I 70I5
Evaluation Rating
I 711
B1
1
72
QA
I N I
73I
1
I I
Reserved
74 71
I
I I
I
I
I
180
Section B: Facility Data
Name and Location of Facility Inspected (For Industrial Users discharging to POTW, also include
POTW name and NPDES Dermit Number)
329 Southwood Drive
329 Southwood Dr
Kernersville NC 27284
Entry Time/Date
02:50PM 21/07/26
Permit Effective Date
20/08/12
Exit Time/Date
03:20PM 21/07/26
Permit Expiration Date
20/10/31
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
///
Other Facility Data
Name, Address of Responsible Official/Title/Phone and Fax Number
Contacted
Walter Lee Tate,329 Southwood Dr Kernersville NC 27284///
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
(See attachment summary)
Name(s) and Signature(s) of Inspector(s) Agency/Office/Phone and Fax Numbers Date
Alex Lowe DWR/WSRO WQ/336-776-9689/
Signature
of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
FDocuSigned by:
L—o, T. StiAcr 8/2/2021
145B49E225C94EA...
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
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31
NPDES yr/mo/day
NCG551106 111 121 21/07/26
117
Inspection Type
18 [j
(Cont.)
1
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
On Monday, July 26, 2021, Alex Lowe of the WSRO conducted a routine Compliance Evaluation
Inspection of the Single -Family Residence treatment system at 329 Southwood Drive in Kernersville.
Mr. Walter Lee Tate led Lowe through the system, and shared the documentation available for review.
Mr. Tate provided the latest copy of his permit, NCG551106. His renewal was submitted last year prior
to permit expiration, and is in review. Annual fees have been paid.
Mr. Tate provided proof that the septic tank was last pumped on October 10, 2019.
Mr. Tate provided proof that a effluent sample was collected and tested by Research & Analytical
Laboratories on October 20, 2020.
Mr. Tate provided a detailed logbook demonstrating chlorine tablet checks conducted on the system.
Effluent pipe was observed, though no discharge was present at the time of inspection.
This system appears to be excellently monitored and maintained.
Page# 2

Permit: NCG551106
Inspection Date: 07/26/2021
Owner - Facility: 329 Southwood Drive
Inspection Type: Compliance Evaluation
Yes No NA NE
Page# 3