NC0037311_LV20150090_20150609

AVA
NCDENR
North Carolina Department of Environment and Natural Resources
Pat McCrory Donald R. van der Vaart
Governor Secretary
June 9,2015
CERTIFIED MAIL#7009 2250 0004 1083 6180 RECEIVED/DENR/DWR
RETURN RECEIPT REQUESTED
William R Hammonds, Consultant Management JUN 1 1 2015
Allegiance Healthcare Investors LLC
PO Box 485
Water Quality
Kernersville,NC 272850485 Permitting Section
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 Permit NC0037311
Allegiance Healthcare Investors LLC
Creekside Manor Assisted Living
Case No.LV-2015-0090
Forsyth County
Dear Mr. Hammonds:
This letter transmits a Notice of Violation and assessment of civil penalty in the amount of$
803.19 ($ 650.00 civil penalty+ $ 153.19 enforcement costs) against the Allegiance Healthcare Investors
LLC.
This assessment is based upon the following facts: a review has been conducted of the discharge
monitoring report (DMR) submitted by the Allegiance Healthcare Investors LLC for the month of
December 2014. This review has shown the subject facility to be in violation of the discharge limitations
and/or monitoring requirements found in NPDES Permit NC0037311. The violations, which occurred in
December 2014, are summarized in Attachment A to this letter.
Based upon the above facts, I conclude as a matter of law that the Allegiance Healthcare
Investors LLC violated the terms, conditions or requirements of NPDES Permit NC0037311 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. 143-215.1(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 Environment and Natural Resources and the Director of
the Division of Water Resources, I, W. Corey Basinger, Water Quality Regional Operations Supervisor
for the Winston-Salem Region,hereby make the following civil penalty assessment against the Allegiance
Healthcare Investors LLC:
450 West Banes Mill Road,Suite 300,Winston-Salem,NC 27105
Phone:[phone] Internet:www.ncwater.org
An Equal Opportunity 1 Affirmative Action Employer-Made in part by recycled paper

1 of the 1 violations of G.S. 143-215.1(aX6)and NPDES Permit No.
$ 100.00 NC0037311,by discharging waste water into the waters of the State in
violation of the Permit Daily Maximum limit for FEC COLI.
1 of the 1 violations of G.S. 143-215.1(aX6)and NPDES Permit No.
$250.00 NC0037311, by discharging wastewater into the waters of the State in
violation of the Permit Monthly Average limit for TSS—Conc.
3 of the 3 violations of G.S. 143-215.1(aX6)and NPDES Permit No.
$300.00 NC0037311,by discharging waste water into the waters of the State in
violation of the Permit Daily Maximum limit for TSS-Conc.
•
$450.00 TOTAL CIVIL PENALTY
$ 153.19 Enforcement Costs
$ 803.19 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 days of receipt of this notice,you must do one of the following:
1. Submit payment of the penalty:
Payment should be made directly to the order of the Department of Environment and Natural Resources
(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:
NC DENR/DWR/NPDES
1617 Mail Service Center
Raleigh,North Carolina 27699-1617
OR
2. Submit a written request for remission 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) were
wrongfully applied to the detriment of the violator;
(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 has 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,
Waiver of Right town Administrative Hearing, and Stipulation of Facts" form within thirty (30) 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:
NC DENR/DWR/NPDES
1617 Mail Service Center
Raleigh,NC 27699-1617
OR
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 original and
one (1) copy of the petition must be filed with the Office of Administrative Hearings. The petition may

be faxed-provided the original and one copy of the document is received in the Office of Administrative
Hearings within five (5) business days following the faxed transmission. The mailing address for the
Office of Administrative Hearings is:
Office of Administrative Hearings
6714 Mail Service Center
Raleigh,NC 27699-6714
Telephone[phone] Facsimile: [phone]
A copy of the petition must also be served on DENR as follows:
John Evans, General Counsel
Department of Environment and Natural Resources
1601 Mail Service Center
Raleigh,NC 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(30) 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 Ron Boone of the Winston-Salem Regional Office at 336-776-
9800.
Sincerely,
.41#44/1
W. Corey Basinger
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources
Attachments
Attachment A
cc: WSRO Files w/attachments
SW Central Files w/attachments
��+'SB-NPDES—Charles Weav

STATE OF NORTH CAROLINA DEPARTMENT OF ENVIRONMENT
AND NATURAL RESOURCES
COUNTY OF FORSYTH
REQUEST FOR REMISSION
Allegiance Healthcare Investors,LLC
IN THE MATTER OF ASSESSMENT ) WAIVER OF RIGHT TO AN
OF CIVIL PENALTIES AGAINST ) ADMINSTRATIVE HEARING AND
Creekside Manor Assisted Living ) STIPULATION OF FACTS
)
)
)
)
PERMIT NO.NC0037311 ) FILE NO. LV-2015-0090
Having been assessed civil penalties totaling $ 803.19 for violation(s) as set forth in the assessment
document of the Division of Water Resources dated 6/9/2015, 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(30)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 ,20
SIGNATURE
ADDRESS
TELEPHONE

•
JUSTIFICATION FOR REMISSION REOUEST
DWQ Case Number: LV-2015-0090 County: Forsyth
Assessed Party: Allegiance Healthcare Investors LLC,Creekside Manor Assisted Living
Permit No.(if applicable):NC0037311 Amount Assessed:$803.19
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 applies. 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. 143B-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 ENVIRONMENTAL MANAGEMENT
COMMISSION
COUNTY OF FORSYTH DWQ Case Number LV-2015-0090
IN THE MATTER OF ASSESSMENT )
OF CIVIL PENALTIES AGAINST: ) REQUEST FOR ORAL PRESENTATION
CREEKSIDE MANOR ASSISTED LIVING )
I hereby request to make an oral presentation before the Environmental Management Commission's
Committee On Civil Penalty Remissions in the matter of the case noted above. In making this request,I
assert that I understand all of the following statements:
• This request will be reviewed by the Chairman of the Environmental Management Commission and
may be either granted or denied.
• Making a presentation will require the presence of myself and/or my representative during a
Committee meeting held in Raleigh,North Carolina.
• My presentation will be limited to discussion of issues and information submitted in my original
remission request, and because no factual issues are in dispute,my presentation will be limited to five
(5)minutes in length.
The North Carolina State Bar's Authorized Practice of Law Committee has ruled that the appearance in a
representative capacity at quasi-judicial hearings or proceedings is limited to lawyers who are active
members of the bar. Proceedings before the Committee on Remissions are quasi-judicial.You should
consider how you intend to present your case to the Committee in light of the State Bar's opinion and
whether anyone will be speaking in a representative capacity for you or a business or governmental entity;
If:you or your representative would like to speak before the Committee,you must complete and return
this form within thirty(30)days of receipt of this letter.
Depending on your status as an individual,corporation,partnership or municipality,the State Bar's
Opinion affects how you may proceed with your oral presentation. See www.ncbar.com/ethics,
Authorized Practice Advisory Opinion 2006-1 and 2007 Formal Ethics Opinion 3.
If you are an individual or business owner and are granted an opportunity to make an oral
presentation before the Committee,then you do not need legal representation before the
Committee;however, if you intend on having another individual speak on your behalf regarding
the factual situations, such as an expert,engineer or consultant,then you must also be present at
the meeting in order to avoid violating the State Bar's Opinion on the unauthorized practice of
law.
• If you are a corporation,partnership or municipality and are granted an opportunity to make an
oral presentation before the Committee,then your representative must consider the recent State
Bar's Opinion and could be considered practicing law without a license if he or she is not a
licensed attorney. Presentation of facts by non-lawyers is permissible.

a 1a1 [ ate"a r+ Mse," s a��9 s; a,:'. i a3 ° as 417,4
ission'Request farm and this Ur Presentation Request form are 't)for i idi\iduals and
ers,your own si attire and?)for corporations,partnerships and municipalities,„,,,,signed„,
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+ c '41,4 a 4 J:4414t g a r
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This the day of , 20
SIGNATURE
TITLE(President, Owner,etc.)
ADDRESS
TELEPHONE( )

ATTACHMENT A
Allegiance Healthcare Investors LLC
CASE NUMBER: LV-2015.0090
PERMIT: NC0037311 FACILITY: Crs.ksId.Manor Assisted Living COUNTY: Forsyth REGION: Winston-Salem
Limit Violations
MONITORING OUTFALL! VIOLATION UNIT OF CALCULATED %OVER
PENALTY REPORT PPI LOCATION PARAMETER DATE FREQUENCY MEASURE LIMIT VALUE UMIT VIOLATION TYPE
$100.00 12-2014 001 Effluent FEC COLI 12/23/14 Weeldy N/100m1 400 12000 2,900.0 Daily Maximum Exceeded
$0.00 12-2014 001 Effluent TSS-Conc 12!5/14 Weekly mgA 45 46.70 3.8 Daily Maximum Exceeded
$0.00 12-2014 001 Effluent TSS-Conc 12/12/14 Weekly mgA 45 50 11.1 Daily Maximum Exceeded
$100.00 12-2014 001 Effluent TSS-Conc 12/23/14 Weekly mgll 45 87.30 49.8 Daily Maximum Exceeded
$250.00 12-2014 001 Effluent TSS-Conc 12/31/14 Weekly mgA 30 48.30 60.8 Monthly Average Exceeded

1
DIVISION OF WATER RESOURCES- CIVIL PENALTY ASSESSMENT
Violator: Allegiance Healthcare Investors,LLC
County: Forsyth
Case Number: LV-2015-0090
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; •
Alt2t‘i. .1;241.-24"4d sAY1'44'***7
2) The duration and gravity 9f the violation;
3) The effect on ground or surface w ter quantity or quality or on air quality;
4) The cost of rectifying the damage;pp
5) The amount of money saved by noncompliance;
•
6) Whether the violation was committed willfully or intentionally;
LA.e" Sok
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
AA
S) The cost to the State of the enforcement procedures. 4(.47, '
Date W.Corey Basinger
Surface Water Regional Supervisor
Winston-Salem Regional Office