NCG550098_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
21I I
Code NPDES yr/mo/day Inspection
I 2 IL I 3 I NCG550098 111 121 21/07/26 117
Type
181OI
I I I I I
Inspector Fac Type
19I S I 2011
I I I I I I I I I I I I I I I I I I I I I I I I I I I
I I I
I I I 1 I P6
Inspection Work Days Facility Self -Monitoring Evaluation Rating B1 QA Reserved
671 I 70I I 711 172 I N I 73I I 74 71
I I
1 1 1 1 1 1 180
Section B: Facility Data
Name and Location of Facility Inspected (For Industrial Users discharging to POTW, also include
POTW name and NPDES Dermit Number)
3050 Cedar Creek Drive
3050 Cedar Creek Dr
Kernersville NC 27284
Entry Time/Date
02:OOPM 21/07/26
Permit Effective Date
20/11/20
Exit Time/Date
02:30PM 21/07/26
Permit Expiration Date
25/10/31
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
Stanley Potoczny,3050 Cedar Creek Dr Kernersville NC 27284/1336-996-7294/
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
rDocuSigned by:
i._0, T. SA,acr 8/2/2021
145�4SEZZ5CT4EA...
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
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31
NPDES yr/mo/day
N CG550098 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 3050 Cedar Creek Drive. Mr. Stanley
Potoczny led Lowe through the system, and shared the documentation available for review.
The permit held by Mr. Potoczny is up to date, but he was unsure whether he had the most up to date
copy. A digital copy of the permit was sent on August 2, 2021.
Mr. Potoczny stated that the septic tank is pumped every three to four years, but could not provide
records of the last pumping. Lowe asked that Mr. Potoczny save the invoice of his next pumping
(likely fall of 2021, according to Mr. Potoczny) for future records and review.
Mr. Potoczny stated that he has not sampled his effluent in the last annual period. Lowe reminded
him that it is a requirement of the permit that an annual sample be collected and tested by an
accredited laboratory.
The chlorination and dechlorination basins were both observed to be in good working order, and the
chlorination tablets were of proper wastewater quality.
A small stream of effluent was observed entereing the receiving stream. It was of excellent clarity, free
from solids or foam. The stream appeared to be healthy, with small fish observed not far downstream
from the outfall.
Upon review of the system, the sand filter appears to be removing all solids, and the chlorination
tablets are being properly monitored and regularly replaced. Please note that regular testing of the
effluent is a requirement of the permit, and should be conducted annually.
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Permit: NCG550098
Inspection Date: 07/26/2021
Owner - Facility: 3050 Cedar Creek Drive
Inspection Type: Compliance Evaluation
Yes No NA NE
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