NCG551139_EPA Form_20220425

EPA
United States Environmental Protection Agency
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 Code NPDES yr/mo/day Inspection Type Inspector Fac Type
1 N 52 NCG551139 22/04/01 C S31112171819 20
21 66
Inspection Work Days Facility Self-Monitoring Evaluation Rating B1 QA ----------------------Reserved-------------------
N67707172 73 74 75 80
Section B: Facility Data
Name and Location of Facility Inspected (For Industrial Users discharging to POTW, also include
POTW name and NPDES permit Number)
569 Beaver Dam Rd
569 Beaver Dam Rd
Roxboro NC 27573
Entry Time/Date Permit Effective Date
Exit Time/Date Permit Expiration Date
12:45PM 22/04/01 20/08/13
Name(s) of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s)
///
Other Facility Data
01:20PM 22/04/01 20/10/31
Name, Address of Responsible Official/Title/Phone and Fax Number
Bobby L Rumley,8003 Rogers Ct Greensboro NC 27455//336-362-1181/Contacted
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Operations & Maintenance Self-Monitoring Program Facility Site Review Effluent/Receiving Waters
Other
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
Chris Smith DWR/RRO WQ/919-791-4200/
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page#1
NPDES yr/mo/day
22/04/01
Inspection Type
C3111218
1
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
All parts of the system appear to be functioning properly after follow up.
Outfall pipe is subsurface and discharges to Hyco Lake. Letter will advise permittee (Mr. Rumley) to
collect a representative effluent sample when it is possible to do so.
Chlorinator was recently covered by sod installation. Mr. Rumley provided photos of the chlorinator
after uncovering it and plans to install a riser around it to allow easy future access. He provided
photos showing that he has the correct chlorine tablets for the system.
This property is a vacation/weekend home and the system is not in daily use.
NCG551139 17 (Cont.)
Page#2
Permit:NCG551139
Inspection Date:04/01/2022
Owner - Facility:
Inspection Type:
569 Beaver Dam Rd
Compliance Evaluation
Other Yes No NA NE
Comment:
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:
Page#3