NC0037311_Owner name Change_20071017

of wAr�
`oa qQG Michael F. Easley, Governor
William G. Ross Jr., Secretary
j r North Carolina Department of Environment and Natural Resources
--1
Coleen H. Sullins, Director
Division of Water Quality
October 17, 2007
MR WILLIAM E HAMMONDS
PO BOX 485
KERNERSVILLE NC 27284
Subject: NPDES Permit Modification — Ownership Change
Permit NCO037311
Creekside Manor Assisted Living WWTP
Formerly Creekside Manor Rest Home WWTP
Forsyth County
Dear Mr. Cheshire:
In accordance with your request received September 28, 2007 the Division is forwarding the subject permit
modification. This modification documents the change in name/ownership at the subject facility. All other terms
and conditions in the original permit remain unchanged and in full effect. This permit modification is issued under
the requirements of North Carolina General Statute 143-215.1 and the Memorandum of Agreement between North
Carolina and the U. S. Environmental Protection Agency dated December 6, 1983.
If any parts, measurement frequencies or sampling requirements contained in this permit
modification are unacceptable to you, you have the right to an adjudicatory hearing upon written request
within thirty (30) days following receipt of this letter. This request must be a written petition conforming
to Chapter 150E of the North Carolina General Statutes, filed with the Office of Administrative Hearings,
Post Office Drawer 27447, Raleigh, North Carolina 27611-7447. Unless such demand is made, this decision
shall be final and binding.
This permit does not affect the legal requirement to obtain other permits, which may be required
by the Division of Water Quality, the Division of Land Resources, Coastal Area Management Act, or any
other Federal or Local government permit that may be required. If you have any questions concerning this
permit, please contact Charles Weaver at 919-733-5083, ext. 511.
Sincerely,
V 7�
�, C teen H. Sullinss
cc: Central Files
Winston-Salem Regional Office, Water Quality Section
NPDES Unit NCO037311
No hCarolma
VVItur"I#
North Carolina Division of Water Quality 1617 Mail Service Center Raleigh, NC 27699-1617 Phone [phone] Customer Service
Internet: www.ncwatcrctuality.org Location: 512 N. Salisbury St. Raleigh, NC 27604 Fax [phone]
An Equal Opportunity/Aflirmative Action Employer - 50% Recycled1100/6 Post Consumer Paper

Permit NCO037311
STATE OF NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER QUALITY
PERMIT
TO DISCHARGE WASTEWATER UNDER THE
NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM
In compliance with the provision of North Carolina General Statute 143-215.1, other lawful
standards and regulations promulgated and adopted by the North Carolina Environmental
Management Commission, and the Federal Water Pollution Control Act, as amended, the
Allegiance Healthcare Investors, LLC
is hereby authorized to discharge wastewater from a facility located at the
Creekside Manor Assisted Living
6206 Reidsville Road
Hernersville
Forsyth County
to receiving waters designated as an unnamed tributary to Belews Creek in
subbasin 03-02-01 of the Roanoke River Basin in accordance with effluent
limitations, monitoring requirements, and other conditions set forth in Parts I, II, III
and IV hereof.
This permit shall become effective October 17, 2007.
This permit and authorization to discharge shall expire at midnight on February 29, 2012.
Signed this day October 17, 2007.
oleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission

Permit NCO037311
SUPPLEMENT TO PERMIT COVER SHEET
All previous NPDES Permits issued to this facility, whether for operation or discharge are hereby
revoked, and as of this issuance, any previously issued permit bearing this number is no longer
effective. Therefore, the exclusive authority to operate and discharge from this facility arises under
the permit conditions, requirements, terms, and provisions included herein.
Allegiance Healthcare Investord,LLC is hereby authorized to:
1. Continue to operate an existing 0.01 MGD extended aeration wastewater
treatment system with the following components:
♦ Bar screen
♦ Aeration basin
♦ Secondary clarifier
♦ Aerobic digester
♦ Chlorination
The facility is located in Kernersville at Creekside Manor Rest Home off Reidsville
Road in Forsyth County.
2. Discharge from said treatment works at the location specified on the attached
map into an unnamed tributary to Belews Creek, classified C waters in subbasin
03-02-01 of the Roanoke River Basin.

NCO037311 — Creekside Manor Assisted Living
Latitude: 36012'49" Sub -Basin: 03-02-01
Longitude: W03'49"
Ouad -Name: Belews Creek
Stream Class: C
Receiving Stream: UT to Belews Creek
Facility:
Location
North Forsyth County
[map not to scale]

Permit NC0037311
A. (1) EFFLUENT LDHTATIONS AND MONITORING REQUIREMENTS
During the period beginning on the effective date of this permit and lasting until
expiration, the Permittee is authorized to discharge from outfall 001. Such discharges
shall be limited and monitored by the Permittee as specified below:
PARAMETER
LIMITS
MONITORING REQUIREMENTS
Monthly
Average
Daily
Maximum
Measurement
Frequency
Sample Type
Sample Location'
Flow
0.010 MGD
Weekly
Instantaneous
Influent or Effluent
BOD, 5-day (20°C)
30.0 mg/L
45.0 mg/L
Weekly
Grab
Effluent
Total Suspended Solids
30.0 mg/L
45.0 mg/L
Weekly
Grab
Effluent
NH3as N
(April 1— October 31
2.0 mg/L
10.0 mg/L
Weekly
Grab
Effluent
NH3as N
November 1— March 31
4.0 mg/L
20.0 mg/L
Weekly
Grab
Effluent
Dissolved Oxygen
Daily average > 5.0 mg/L
Weekly
Grab
Effluent
Dissolved Oxygen
Weekly
Grab
Upstream &
Downstream
Fecal Coliform
(geometric mean
200/100 ml
400/100 ml
Weekly
Grab
Effluent
Total Residual Chlorine (TRC)2
17 /ug/L
2/Week
Grab
Effluent
Temperature (°C)
Daily
Grab
Effluent
Temperature (QC)
Weekly
Grab
Upstream &
Downstream
pH
> 6.0 and < 9.0 standard units
Weekly
Grab
Effluent
Footnotes:
1. Upstream: approximately 100 feet upstream from the outfall.
Downstream: approximately 300 feet downstream from outfall.
2. TRC limit takes effect May 1, 2009. Until that time, the Permittee shall monitor
TRC [with no effluent limit] . Limit and monitoring requirements apply ONLY if
chlorine is used for disinfection.
There shall be no discharge of floating solids or visible foam in other than trace amounts

0", L4 9 D
r SEP 2 8 2007
NAME/OWNERSHIP
Michael F. Easley, Governor
William G. Ross Jr., Secretary
Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E, Director
Division of Water Quality
SECTION
T FORM
I. Please enter the permit number for which the change is requested.
NPDES Permit (or) Certificate of Coverage
N I C 10 jo I N I C I G
II. Permit status prior to status change.
a. Permit issued to (company name): {�i �KGE ✓�Alvrlki�M EN T C 20 v P
b. Person legally responsible for permit: —DF}V IT> f} • &fj Ll ti16�.
First / MI / Last
Title
(oZ0(p 1�E1Tj51V ILLS
Rp
Permit Holder Mailing Address
KN��VII.I Nc-
Z7 2--s-Lf
Ciry State
Zip
Phone Fax
c. Facility name (discharge): GQrEp-� KS 1 DE ihi gxok
d. Facility address: 1p 2©(P AEI 6 V I LLE
Address
K .lug �-s v I I,LE nlC-
Z 7 z 941
City State
e. Facility contact person: AWlE5 U e59I A E (33&
Zip
q 9(0 -
First / MI / Last Phone
III. Please provide the following for the requested change (revised permit).
a. Request for change is a result of:
If other please explain:
b. Permit issued to (company name):
c. Person legally responsible for permit:
d. Facility name (discharge):
e. Facility address:
f Facility contact person:
5f Change in ownership of the facility
L Name change of the facility or owner
YiPY1')PXSV l t I ei IJ G 2429y
�JQ,rW5 L.he�hlre. Zip
First / MI / Last
(3)6) UP.2$d1
Phone E-mail Address
Revised 7/2005

PERMIT NAME/OWNERSHIP CHANGE FORM
Page 2 of 2
IV. Permit contact information: (if different from the person legally responsible for the permit)
Permit contact:
First / MI / Last
Title
Mailing Address
City State Zip
Phone E-mail Address
V. Will the permitted facility continue to conduct the same industrial activities conducted prior to
this ownership or name change?
O/Yes
❑ No (please explain)
VI. Required Items: THIS APPLICATION WILL BE RETURNED UNPROCESSED IF ITEMS ARE
INCOMPLETE OR MISSING.
❑ This completed application is required for both name change and/or ownership change requests.
❑ Legal documentation of the transfer of ownership (such as relevant pages of a contract deed, or a bill
of sale) is required for an ownership change request. Articles of incorporation are not sufficient for
an ownership change.
...................................................................................................
The certifications below must be completed and signed by both the permit holder prior to the change, and the new
applicant in the case of an ownership change request. For a name change request, the signed Applicant's Certification
is sufficient.
PERMITTEE CERTIFICATION (Permit holder prior to ownership change):
I, Q "to Q � &LLV, attest that this application for a name/ownership
change has been reviewed and is acc ate and complete to the best of my knowledge. I understand that if all required
parts of this application are not completed and that if all required supporting information is not included, this
applicati kage will be returne incomplete.
/12-- o
Signature Da
APPLICANT CERTIFICATION:
I, A7, r`T4i` M60As , attest that this application for a name/ownership
change has been reviewed and is accurate and complete to the best of my knowledge. I understand that if all required
parts of this application are not completed and that if all required supporting information is not included, this
application package will be returned as incomplete.
�- /J 4a7 >2-. A-7
Signature D tc
.................. .
PLEASE SEND THE COMPLETE APPLICATION PACKAGE TO:
Division of Water Quality
Surface Water Protection Section
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Revised 7/2005

of
• D
• NORTH CAROLINA )
REAL ESTATE PURCHASE AGREEMENT
FORSYTH COUNTY )
THIS AGREEMENT made and entered this the I" day of May, 2002, by and between
Pierce Management Group First Partnership of Forsyth County, North Carolina, Party of the First
Part, hereinafter referred to as "Seller" and Allegiance Health Care Investors, LLC of Forsyth
County, North Carolina, Party of the Second Part, hereinafter referred to as 'Buyer".
WITNESSETH
WHEREAS, Seller is seized of a marketable fee simple absolute interest in a certain parcel
of real estate known as Creekside Manor Assisted Living of Forsyth County located at 6206
Reidsville Road, Belews Township, Forsyth County, Kernersville, North Carolina 27284; and more
particularly described in the attached Exhibit A; and
WHEREAS, Buyer desires to purchase the parcel of real estate owned by Seller, together
• with all fixtures, equipment, inventory and famishing located within the building at Creekside Manor
Assisted Living of Forsyth County, 6206 Reidsville Road, Forsyth County, Kernersville, North
Carolina 27284, more particularly described in the attached Exhibit A; and
WHEREAS, Seller desires to sell the parcel of real estate, all fixtures, equipment, inventory
and furnishings located at 6206 Reidsville Road, Forsyth County, Kemersville, North Carolina
27284, more particularly described in the attached Exhibit A; and
WHEREAS, the parties desire to memorialize in writing their agreement regarding the
purchase of said parcel of real estate located at 6206 Reidsville Road, Forsyth County, Kernersville,
North Carolina 27284, more particularly described in the attached Exhibit A; and
NOW, THEREFORE, in consideration of the mutual covenants and conditions set forth
herein, the parties do mutually agree as follows:
CONTRACT TO PURCHASE
That in consideration of TEN DOLLARS and other valuable consideration paid simultaneous
herewith unto the Seller, the Seller agrees to give, grant and convey unto the Buyer that certain parcel
of real estate more particularly described in Exhibit A attached hereto, which is incorporated
herewith by reference as if fully set out. In addition thereto, the Seller shall convey unto the Buyer
any and all interest which it may have in the fixtures, equipment, furnishings, and inventory of the

• (c) The parties agree that the terms and provisions of this Agreement shall be binding
upon and inure to the benefit of the parties, their heirs, executors, administrators, successors in
interest and assigns.
(d) The parties agree that the terns and provisions of this Agreement shall be construed
in accordance with the laws of the State of North Carolina.
(e) This Agreement contains the entire agreement between the parties. There is merged
herein all prior and collateral representations, promises, and conditions in connection with the
subject matter hereof. Any representation, promise or condition not incorporated herein shall not be
binding upon either party.
(f) The acknowledgement or acceptance of any term or condition inconsistent with this
Agreement shall not be deemed an acceptance or approval of such inconsistent provisions.
IN WITNESS WHEREOF, the parties have hereunto set their hands and seals this 5+
day of 2002.
BUYER:
Allegiance Health Care Investors, LLC
ll'a,r 4 (SEAL)
William R. HammondS 6ce
%
l i � (SEAL)
Candace Hammond S
SELLER:
Pierce Management Group First Partnership
e4 ��L ��C.),c (SEAL)
A. Steve Pierce, General Partner
11