NC0028941_NOD2016PC0095_20160420 (2)

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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 NCO028941 I11 121 16/04/19 117 18 I r l 19 I c I 20I
21111111 111111111111111111 1111111 11111111111 166
Inspection Work Days Facility Self-Monitoring Evaluation Rating B1 QA ------Reserved--------
67 1.0 7014 1 71 1itN J 1 72 1 N 1 731 I 174 75I 1 1 I I 1 1 180
I-J Section B:Facility Data
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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) 12,35PM 16/04/19 14/04/01
Pine Valley Subdivision WWTP
NCSR 1802 Exit Time/Date Permit Expiration Date
01:30PM 16/04/19 19/03/01
Salisbury NC 28144
Name(s)of Onsite Representative(s)rritles(s)/Phone and Fax Number(s) Other Facility Data
/N
John David Wall/1704-507-3365%
John David Wall/ORC/704-507-3765/
Name,Address of Responsible Officialrritle/Phone and Fax Number
Contacted
Thomas J Roberts,202 Mackenan Ct Cary NC
No
27511/President/919-467-3712/9194601788
Section C:Areas Evaluated During Inspection(Check only those areas evaluated)
® Permit ® Flow Measurement ® Operations&Maintenance ® Records/Reports
® Self-Monitoring Program ® Sludge Handling Disposal ® Facility Site Review ® Effluent/Receiving Waters
Laboratory
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
On A Tuvia MRO WQ//704-663-1699/
116
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
W.Corey Basinger MRO WQ//704-235-2194/
EPA Form 3560-3(Rev 9-94)Previous editions are obsolete
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NPDES yr/mo/day Inspection Type 1
31 NCO028941 (11 12I 16/04/19 117 18 ICI
Section D:Summary of Finding/Comments(Attach additional sheets of narrative and checklists as necessary)
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