NCG550520_Compliance Evaluation Inspection_20221128 (2)

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)
1
21IIIIII
671
Transaction Code NPDES yr/mo/day Inspection
IN I 2 IL I 3 I NCG550520 111 121 22/11/09 117
Type
1810I
IIIIIIIIIII
Inspector Fac Type
19I S I 2011
IIIIIIIIIII IIIIIII I IIIIII
P6
Inspection Work Days Facility Self -Monitoring Evaluation Rating B1 QA Reserved
I 70I I 711 172 I N I 73I 1 74 71
I I
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)
1991 Clover Trail
1991 Clover Trl
Walkertown NC 27051
Entry Time/Date
09:OOAM 22/11/09
Permit Effective Date
21/08/24
Exit Time/Date
09:30AM 22/11/09
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
Danny Ward,1991 Clover Trl Walkertown NC 27051//336-595-3030/
No
Section C: Areas Evaluated During Inspection (Check only those areas evaluated)
Permit
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
Gary Hudson DWR/Division of Water Quality/336-776-9694/
Signature
of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
1DocuSigned by: 11/21/2022
L,,ti T. StiAcr
145B49E225C94EA...
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
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3I
NPDES yr/mo/day
N CG550520 111 121 22/11/09
117
Inspection Type
18 [j
1
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
*The single-family subsurface sand filter appeared to be very well maintained.
*Mr. Ward keeps very good records on the system.
*The septic tank is pumped and inspected every three to five years.
*The effluent pipe was located, and a clear path is maintained to facilitate sampling.
*The system was not discharging during the time of the inspection.
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Permit: NCG550520
Inspection Date: 11/09/2022
Owner - Facility: 1991 Clover Trail
Inspection Type: Compliance Evaluation
Permit Yes No NA NE
(If the present permit expires in 6 months or less). Has the permittee submitted a new El El ❑
application?
Is the facility as described in the permit? • El El El
# Are there any special conditions for the permit? El El • El
Is access to the plant site restricted to the general public? ❑ ❑ • ❑
Is the inspector granted access to all areas for inspection? • El El El
Comment:
Page# 3