NCG550596_ncg550596 EPA form CEI 11.07.2024_20241107

Docusign Envelope ID: EB9053DF-3872-4C71-948F-02F38AC90220
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 u 3 I NCG550596 111 121 24/10/17 I17 18 I C I 19 I G I 20U
21111I I I 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 I r6
Inspection Work Days Facility Self-Monitoring Evaluation Rating B1 QA ----------------------Reserved-------------------
67 70 J 71 Ity 72 L-J 73 1 74 79 I I I I 80
Section B: Facility Data
Name and Location of Facility Inspected(For Industrial Users discharging to POTW,also include Entry Time/Date Permit Effective Date
POTW name and NPDES Dermit Number) 01:47PM 24/10/17 20/03/30
6915 Innesbrook Way
6915 Innesbrook Way Exit Time/Date Permit Expiration Date
Bahama NC 27503 02:03PM 24/10/17 20/10/31
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
Charles Guidry,6915 Innesbrook Way Bahama NC 27503///
No
Section C:Areas Evaluated During Inspection (Check only those areas evaluated)
Permit 0 Flow Measurement Operations&Maintenar 0 Facility Site Review
Effluent/Receiving Wate
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
Stephen D Smith DWR/RRO WQ/919-791-4200/
DocuSigned by:
11/13/2024
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
Signed by:
Ucu so, f. t1Adn ttt 11/13/2024
EPA Form 3560-3(Rev 9-94)Previous editions are obsolete.
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Docusign Envelope ID: EB9053DF-3872-4C71-948F-02F38AC90220
NPDES yr/mo/day Inspection Type 1
31 NCG550596 I11 12I 24/10/17 11 7 18 i c i
Section D: Summary of Finding/Comments (Attach additional sheets of narrative and checklists as necessary)
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Docusign Envelope ID: EB9053DF-3872-4C71-948F-02F38AC90220
Permit: NCG550596 Owner-Facility: 6915 Innesbrook Way
Inspection Date: 10/17/2024 Inspection Type: Compliance Evaluation
Operations & Maintenance Yes No NA NE
Is the plant generally clean with acceptable housekeeping? 0 ❑ ❑ ❑
Does the facility analyze process control parameters, for ex: MLSS, MCRT, Settleable ❑ ❑ ❑
Solids, pH, DO, Sludge Judge, and other that are applicable?
Comment: Single Family Residence wastewaer system consisting of septic tank, single pass
gravity sandfitler, chlorinator, de-chlorinator, and an outlet.
Permit Yes No NA NE
(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? ❑ ❑ 0 ❑
Is access to the plant site restricted to the general public? 0 ❑ ❑ ❑
Is the inspector granted access to all areas for inspection? ■ ❑ ❑ ❑
Comment:
Effluent Pipe Yes No NA NE
Is right of way to the outfall properly maintained? 0 ❑ ❑ ❑
Are the receiving water free of foam other than trace amounts and other debris? ❑ ❑ 0 ❑
If effluent (diffuser pipes are required) are they operating properly? ❑ ❑ 0 ❑
Comment:
De-chlorination Yes No NA NE
Type of system ? Tablet
Is the feed ratio proportional to chlorine amount (1 to 1)? ❑ ❑ 0 ❑
Is storage appropriate for cylinders? ❑ ❑ 0 ❑
# Is de-chlorination substance stored away from chlorine containers? 0 ❑ ❑ ❑
Comment:
Are the tablets the proper size and type? 0 ❑ ❑ ❑
Are tablet de-chlorinators operational? ❑ ❑ ❑ ■
Number of tubes in use?
Comment:
Disinfection-Tablet Yes No NA NE
Are tablet chlorinators operational? 0 ❑ ❑ ❑
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Docusign Envelope ID: EB9053DF-3872-4C71-948F-02F38AC90220
Permit: NCG550596 Owner-Facility: 6915 Innesbrook Way
Inspection Date: 10/17/2024 Inspection Type: Compliance Evaluation
Disinfection-Tablet Yes No NA NE
Are the tablets the proper size and type? 0 ❑ ❑ ❑
Number of tubes in use?
Is the level of chlorine residual acceptable? ❑ ❑ 0 ❑
Is the contact chamber free of growth, or sludge buildup? ❑ ❑ ❑
Is there chlorine residual prior to de-chlorination? ❑ ❑ ❑
Comment:
Sand Filters (Low rate) Yes No NA NE
(If pumps are used) Is an audible and visible alarm Present and operational? ❑ ❑ 0 ❑
Is the distribution box level and watertight? ❑ ❑ 0 ❑
Is sand filter free of ponding? ❑ ❑ ■ ❑
Is the sand filter effluent re-circulated at a valid ratio? ❑ ❑ 0 ❑
# Is the sand filter surface free of algae or excessive vegetation? ❑ ❑ 0 ❑
# Is the sand filter effluent re-circulated at a valid ratio? (Approximately 3 to 1) ❑ ❑ ■ ❑
Comment: Septic tank, single pass sub-surface sandfilter,
Septic Tank Yes No NA NE
(If pumps are used) Is an audible and visual alarm operational? ❑ ❑ ■ ❑
Is septic tank pumped on a schedule? M ❑ ❑ ❑
Are pumps or syphons operating properly? ❑ ❑ ❑
Are high and low water alarms operating properly? ❑ ❑ 0 ❑
Comment:
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