NCG550058_Compliance Evaluation Inspection_20230302

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 IN 1 2 15 1 3 I NCG550058 111 121 23/02/06 117 181 C I 19 I S I 20I
211111 1 1 I I I I II I I I I I I I I I I I I I I I I I I I I I I I II I I I I 1166
Inspection Work Days Facility Self -Monitoring Evaluation Rating B1 QA ---------------------- Reserved -------------------
67I I 701 I 71 I I 72 I N I 731 I 74 7
u u
80
Section B: FacilityDataData
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)
02:30PM 23/02/06
07/08/01
4669 Paula Drive
Exit Time/Date
Permit Expiration Date
4669 Paula Dr
Winston Salem NC 27127
02:45PM 23/02/06
12/07/31
Name(s) of Onsite Rep resentative(s)/Titles(s)/Phone and Fax Number(s)
Other Facility Data
///
Name, Address of Responsible Official/Title/Phone and Fax Number
Contacted
William S Rivers,4669 Paula Dr Winston Salem NC 27127N
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/
DocuSigned by:
Ras", 2/28/2023
SignaTure o��ilcanagement Q A Reviewer Agency/Office/Phone and Fax Numbers Date
DocuSigned by:
2/28/2023
FLam - -T. '5 ,,dc>_
"- 145ME225CMEA...
EPA Form 3560-3 (Rev 9-94) Previous editions are obsolete.
Page#

NPDES yr/mo/day Inspection Type
NCG550058 I11 12I 23/02/06 117 18 ICI
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
*The current homeowner needs to sumit an"Ownership Change Form."
*October 31, 2022 — "Please Contact Me" letter sent.
*December 6, 2022 - "Please Contact Me" letter sent.
*January 6, 2023 - "Please Contact Me" letter sent, Certified Mail. Letter was "Return to Sender."
*February 6, 2023 — Made site visit. The home appeared occupied, with no one home. Spotted what I
believed to be the chlorinator in an easement behind the house. Walked the creek but found no
discharge pipe.
Page#

Permit: NCG550058
Inspection Date: 02/06/2023
Permit
Owner -Facility: 4669 Paula Drive
Inspection Type: Compliance Evaluation
(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 current homeowner needs to sumit an"Ownership Change Form."
Yes No NA NE
❑ ❑ ❑ ❑
Page# 3