NC0071897_LV20160206_20161017

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Certified Mail # 70151520 0003 5463 0073
Return Receipt Requested
October 17, 2016
Henderson's Assisted Living
Mizpah Healthcare Inc
74 Lotus Lane
Hendersonville, NC 28792
SUBJECT: Notice of Violation and Assessment of Civil Penalty
for Violations of North Carolina General Statute (G.S.) 143-215.1(a)(6)
and NPDES WW Permit No. NCO071897
Mizpah Healthcare Inc
Henderson's Assisted Living WWTP
Case No. LV -2016-0206
Henderson County
Dear Permittee:
RECEltoEMCDEQUA
OCT 2 0 2016
Water Quality
Permitting Section
This letter transmits a Notice of Violation and assessment of civil penalty in the amount of $366.62 ($250.00 civil penalty +
$116.62 enforcement costs) against Mizpah Healthcare Inc.
This assessment is based upon the following facts: a review has been conducted of the discharge monitoring report (DMR)
submitted by Mizpah Healthcare Inc for the month of April 2016. This review has shown the subject facility to be in
violation of the discharge limitations and/or monitoring requirements found in NPDES WW Permit No. NC0071897. The
violations, which occurred in April 2016, are summarized in Attachment A to this letter.
Based upon the above facts, I conclude as a matter of law that Mizpah Healthcare Inc violated the terms, conditions or
requirements ofNPDES WW Permit No. NCO071897 and G.S. 143-215.1(a)(6) in the manner and extent shown in
Attachment A. In accordance with the maximums established by G.S. 143-215.6A(a)(2), a civil penalty may be assessed
against any person who violates the terms, conditions or requirements of a permit required by G.S. 143-215. l(a).
Based upon the above findings of fact and conclusions of law, and in accordance with authority provided by the Secretary
of the Department of Environmental Quality and the Director of the Division of Water Resources, I, G. Landon Davidson,
P.G., Regional Supervisor, Asheville Regional Office hereby make the following civil penalty assessment against Mizpah
Healthcare Inc:
State of North Carolina I Environmental Quality I Water Resources
2090 U.S. 70 Highway, Swannanoa, NC 28778 -
828-296-4500

$250.00 1 of the 1 violations of 143-215.1(a)(6) and Permit No.NC0071897, by discharging wastewater into
the waters of the State in violation of the Permit Monthly Average for FLOW.
$250.00 TOTAL CIVIL PENALTY
$116.62 Enforcement Costs
$366.62 TOTAL AMOUNT DUE
Pursuant to G.S. 143-215.6A(c), in determining the amount of the penalty I have taken into account the Findings of Fact and
Conclusions of Law and the factors set forth at G.S. 143B -282.1(b), which are:
(1) The degree and extent of harm to the natural resources of the State, to the public health, or to private property
resulting from the violation;
(2) The duration and gravity of the violation;
(3) The effect on ground or surface water quantity or quality or on air quality; .
(4) The cost of rectifying the damage;
(5) The amount of money saved by noncompliance;
(6) Whether the violation was committed willfully or intentionally;
(7) The prior record of the violator in complying or failing to comply with programs over which the Environmental
Management Commission has regulatory authority; and
(8) The cost to the State of the enforcement procedures.
Within thirty (30) days of receipt of this notice, you must do one of the following:
(1) Submit payment of the penalty, OR
(2) Submit a written request for remission, OR
(3) Submit a written request for an administrative hearing
Option 1: Submit payment of the penalty:
Payment should be made directly to the order of the Department of Environmental Quality (do not include waiver
form). Payment of the penalty will not foreclose further enforcement action for any continuing or new violation(s).
Please submit payment to the attention of.
Wastewater Branch
Division of Water Resources
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

Option 2: Submit a written request for remission or mitigation including a detailed justification for such
request:
Please be aware'that a request for remission is limited to consideration of the five factors listed below as they may
relate to the reasonableness of the amount of the civil penalty assessed. Requesting remission is not the proper
procedure for contesting whether the violation(s) occurred or the. accuracy of any of the factual statements contained in
the civil penalty assessment document. Because a remission request forecloses the option of an administrative hearing,
such a request must be accompanied by a waiver of your right to an administrative hearing and a stipulation and
agreement that no factual or legal issues are in dispute. Please prepare a detailed statement that establishes why you
believe the civil penalty should be remitted, and submit it to the Division of Water Resources at the address listed below.
In determining whether a remission request will be approved, the following factors shall be considered:
(1) whether one or more of the civil penalty assessment factors in NCGS 143B -282.1(b) was wrongfully
applied to the detriment of the petitioner;
(2) whether the violator promptly abated continuing environmental damage resulting from the violation;
(3) -whether the violation was inadvertent or a result of an accident;
(4) whether the violator had been assessed civil penalties for any previous violations; or
(5) whether payment of the civil penalty will prevent payment for the remaining necessary remedial actions.
Please note that all evidence presented in support of your request for remission must be submitted in writing. The
Director of the Division of Water Resources will review your evidence and inform you of his decision in the matter of
your remission request. The response will provide details regarding the case status, directions for payment, and .
provision for further appeal of the penalty to the Environmental Management Commission's Committee on Civil Penalty
Remissions (Committee). Please be advised that the Committee cannot. consider information that was not part of the
original remission request considered by the Director. Therefore, it is very important that you prepare a complete and
thorough statement in support of your request for remission:
In order to request remission you must complete and submit the enclosed "Request for Remission of Civil Penalties,
Waiver of Right to an Administrative Hearing and Stipulation of Facts" form within thirty Q 0) days of receipt of this
notice The Division of Water Resources also requests that you complete and submit the enclosed "Justification for
Remission Request."
Both forms should be submitted to the following address:
Wastewater Branch
Division of Water Resources
1617 Mail Service Center
Raleigh, North Carolina 27699-1617

Option 3: File a petition for an administrative hearing with the Office of Administrative Hearings:
If you wish to contest any statement in the attached assessment document you must file a petition for an administrative
hearing. You may obtain the petition form from the Office of Administrative Hearings. You must file the petition with
the Office of Administrative Hearings within thirty (30) days of receipt. of this notice. A petition is considered filed
when it is received in the Office of Administrative Hearings during normal office hours. The Office of Administrative
Hearings accepts filings Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m., except for official state
holidays. The petition may be filed by facsimile (fax) or electronic mail by an attached file (with restrictions) - provided
the signed original, one (1) copy and a filing fee (if a filing fee is required by NCGS § 150B-23.2) is received in the
Office of Administrative Hearings within seven (7) business days following the faxed or electronic transmission. You
should contact the Office of Administrative Hearings with all questions reizarding the filing fee and/or the details of the
filing process.
The mailing address and telephone and fax numbers for the Office of Administrative Hearings are as follows:
Office of Administrative Hearings
6714 Mail Service Center
Raleigh, NC 27699-6714
Tel: [phone]
Fax: [phone]
One (1) copy of the petition must also be served on DEQ as follows:
Mr. Sam M. Hayes, General Counsel
Department of Environmental Quality
1601 Mail Service Center
Raleigh, North Carolina 27699-1601
Please indicate the case number (as found on page one of this letter) on the petition.
Failure to exercise one of the options above within thirty (3 0) days. of receipt of this letter, as evidenced by an internal
date/time received stamp (not a postmark), will result in this matter being referred to the Attorney General's Office for
collection of the penalty through a civil action. Please be advised that additional penalties may be assessed for violations
that occur after the review period of this assessment.
If you have any questions, please contact Janet Cantwell with the Division of Water Resources staff of the Asheville
Regional Office at [phone] or via email [e-mail].
Sincerely,
G. Landon Davidson, P.G., Regional Supervisor
Water Quality Regional Operations Section
Asheville Regional Office
Division of Water Resources, NCDEQ
ATTACHMENTS
Cc: WQS Asheville Regional Office - Enforcement File
NPDES Compliance/Enforcement Unit - Enforcement File
James & James Environmental/ ORC
G:+.4VR`�VQI[Tendecsun\Wa;te+arerl�liwrs flendtrson's Assisted Living 71897LV-2-0I 6-0206.af

JUSTIFICATION FOR REMISSION REQUEST
Case Number: LV -2016-0206
Assessed Party: Mizpah Healthcare Inc
PermitNo.: NC0071897
County: Henderson
Amount Assessed: $366.62
Please use this form when requesting remission of this civil penalty. You must also complete the "Request For Remission,
Waiver of Right to an Administrative Hearing, and Stipulation of Facts" form to request remission of this civil penalty.
You should attach any documents that you believe support your request and are necessary for the Director to consider in
evaluating your request for remission. Please be aware that a request for remission is limited to consideration of the five
factors listed below as they may relate to the reasonableness of the amount of the civil penalty assessed. Requesting
remission is not the proper procedure for contesting whether the violation(s) occurred or the accuracy of any of the factual
statements contained in the civil penalty assessment document. Pursuant to N.C.G.S. § 143B -282.1(c), remission of a civil
penalty may be granted only when one or more of the following five factors apply. Please check each factor that you
believe applies to your case and provide a detailed explanation, including copies of supporting documents, as to why the
factor applies (attach additional pages as needed)".
(a) one or more of the civil penalty assessment factors in N.C.G.S. 14313-282.1(b) were wrongfully applied to the
detriment of the petitioner (the assessment factors are listed in the civil penalty assessment document);
(b) the violator promptly abated continuing environmental damage resulting from the violation (i.e., explain the
steps that you took to correct the violation and prevent future occurrences);
(c) the violation was inadvertent or a result of an accident (i.e., explain why the violation was unavoidable or
something you could not prevent or prepare for);
(d) the violator had not been assessed civil penalties for any previous violations;
(e) payment of the civil penalty will prevent payment for the remaining necessary remedial actions (i.e., explain
how payment of the civil penalty will prevent you from performing the activities necessary to achieve
compliance).
EXPLANATION:

STATE OF NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
COUNTY OF HENDERSON
IN THE MATTER OF ASSESSMENT ) WAIVER OF RIGHT TO AN
OF CIVIL PENALTIES AGAINST ) ADDIINISTRATIVE HEARING AND
STIPULATION OF FACTS
Mizpah Healthcare Inc )
Henderson's Assisted Living WWTP )
PERMIT NO. NCO071897 ) CASE NO. LV -2016-0206
Having been assessed civil penalties totaling $366.62 for violation(s) as set forth in the assessment document of the Division
of Water Resources dated October 17, 2016, the undersigned, desiring to seek remission of the civil penalty, does hereby
waive the right to an administrative hearing in the above -stated matter and does stipulate that the facts are as alleged in the
assessment document. The undersigned further understands that all evidence presented in support of remission of this civil
penalty must be submitted to the Director of the Division of Water Resources within thirty (3 0) days of receipt of the notice .
of assessment. No new evidence in support of a remission request will be allowed after (30) days from the receipt of the
notice of assessment.
This the
day of
F.11 9191
TELEPHONE
SIGNATURE
NZ

I ATTACHMENT A
Mizpah Healthcare Inc
CASE NUMBER: LV -2016-0206.
PERMIT: NCO071897 REGION: Asheville
FACILITY: Henderson's Assisted Living WWTP COUNTY: Henderson
LIMIT VIOLATION(S)
SAMPLE LOCATION: Outfall 001 - Effluent
Violation Report
Date MonthNr Parameter
4/30/2016 4-2016 Flow, in conduit or thru
treatment plant.
Unit of
Limit
Calculated
% Over
Violation
Penalty
Frequency Measure
Value
Value
Limit
Type
Amount
Weekly mgd
0.01
0.00
35.7
Monthly
$250.00
Average
Exceeded

DIVISION OF WATER RESOURCES - CIVIL PENALTY ASSESSMENT (File)
Violator: Mizpah Healthcare Inc
Facility Name: Henderson's. Assisted Living WWTP
Permit Number: NCO071897
County: Henderson
Case Number: LV -2016-0206
ASSESSMENT FACTORS
1) The degree and extent of harm to the natural resources of the State, to the public health, or to private property
resulting from the violation;
All effluent violations may be detrimental to the receiving stream but may not be immediately quantified.
2) The duration and gravity of the violation;
One Monthly Average FLOW exceeded the permit limit by 35.7%.
3) The effect on ground or surface water quantity or quality or on air quality;
All effluent violations may be detrimental to the receiving stream but may not be immediately quantified.
4) The cost of rectifying the damage;
The cost is unknown.
5) The amount of money saved by noncompliance;
The amount of money saved would include the cost of investigating why the Flow exceeded the permit limit.
6) Whether the violation was committed willfully or intentionally;
It does not appear to be either.
7) The prior record of the violator in complying or failing to comply with programs over which the Environmental
Management Commission has regulatory authority; and
There have been two civil penalty enforcements in the twelve months prior to this violation.
8) The cost to the State of the enforcement procedures.
$116.62
Date G. Landon Davidson, P.G., Regional Supervisor
Water Quality Regional Operations Section
Asheville Regional Office
Division of Water Resources, NCDEQ

F "
NPDES PERMIT NO. NCO071897 DISCHARGE NO. 001 MONTH APRIL YEAR 2016 .
FACILITY NAME HENDERSON'S ASSISTED LIVING CLASS II COUNTY HENDERSON
CERTIFIED LABORATORY (1) JAMES & JAMES ENVIRONMENTAL MGT., INC. CERTIFICATION NO. 482
(list additional laboratories on the backside/page 2 of this form)
OPERATOR IN RESPONSIBLE' CHARGE (ORC) KEVIN BRYAN GRADE II CERTIFICATION NO. 1002130
PERSON(S) COLLECTING SAMPLES KEVIN BRYAN ORC PHONE [phone]
CHECK BOX IF ORC HAS CHANGED I NO FLOW/ DISCHARGE FROM SITE *
Mail ORIGINAL and ONE COPY to:
ATTN: CENTRAL FILES x� ` / 5/25/2016
DIVISION OF WATER QUALITY -(61UN iI UXh UP OF INbISL1-ChAKkj
1617 MAIL SERVICE CENTER BY THIS SIGNATURE, I CERTIFY THAT THIS REPORT IS
RALEIGH, NC 27699-1617 ACCURATE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. A.
AVERAGE
0.0101
17.6
=
0.0
3.7
0.4 1
10.8
0.0 1
7.5
MAXOMUM
0.014
19.4
7.7
<15
5.8
1.0
20.7
<1.0
8.8
MINIMUM
0.001
15.7
6.9
<15
2.3
<0.1
5.6
<1.0
6.2
Comp. (C) / Grab G)
G
G
G
G
G
G
G
G
G
Monthly Limit
0.007
NL
6-9
17
5.017.5
2.0/10.0
30/45
00/40
>6.0
DWQ Farm MIR -1(11104)
Aox-
9 / � /Vd ✓- 2-016-1-V-06- /p j�l/s��/i �..1�- ?.�/6 - 0 Z 0

Facility Status: (Please check one of the following)
All monitoring data and sampling frequencies meet permit
(including weekly averages, if applicable)
. . All monitoring data and sampling frequencies do NOT meet permit
Compliant
Noncompliant
The permittee shall report to the Director or the appropriate Regional Office any noncompliance that potentially threatens public health or the
environment. Any information shall be provided orally within 24 hours from the time the permittee became aware of the circumstances. A written
submission shall also be provided within 5 days of the time the permittee becomes aware of the circumstances.
If the facility is noncompliant, please attach a list of corrective actions being taken and a time -table for improvements to be made as, required by Part II.E.6 of
the NPDES permit.
"I. certify, under penalty of law, `thakhis document and all attachment's were prepared under my direction or supervision in accordance with a system designed to assure
that qualified personnel properly gather and evaluate the information submitted. Based on my inquiry of the person or persons who managed the system, or those persons
directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there
are significant penalties for submitting false information, including the possibility of fines and imprisonment for ]mowing violations."
HENDERSON'S ASSISTED LIVING
Permittee (Please print or type)
'Viv i e 5/25/2016
Sigyature of Permitte ** Date
equired unless submitted electronically) .
602 BROOKSIDE CAMP RD, HENDERSONVILLE;NC 28792 828-697-0063 11-30-15
Pernuttee Address Phone Number e-mail address Permit Expiration Date
Certified Laboratory (2)
Certified Laboratory (3)
Certified Laboratory (4)
Certified Laboratory (5)
- ADDITIONAL CERTIFIED LABORATORIES
PARAMMTER CODES
Certification No.
Certification No.
Certification No.
Certification No.
Parameter Code assistance may be obtained by calling the NPDES Unit at [phone] or by visiting hq-.1/portal.ncdenr.orglweb/wq/swp/ps/npdestappforms.
Use only unitsof measurement designated in the reporting facility's NPDES permit for reporting data.
* No Flow/Discharge. From Site: Check this box if no discharge occurs and, as a result, there are no data to be
entered for all of the parameters on the DMR for the entire monitoring period.
** ORC On Site?: ORC must visit facility and document visitation of facility as required per 15A NCAC 8G.0204.
*** Signature of Permittee: If signed by other than the permittee, then the delegation of the signatory authority must be on
file with the state per 15A NCAC 2B .0506(b)(2)(D). .