NC0037311_Compliance Evaluation Inspection_20151116

North Carolina Department of Environmental Quality
Pat McCrory Donald R.van der Vaart
Governor Secretary
November 16, 2015
Allegiance Healthcare Investors, LLC
Attn:William R. Hammonds, Consultant Management
P.O. Box 485
Kernersville, NC 27284-0485
SUBJECT: Compliance Evaluation Inspection
Creekside Manor Assisted Living Wastewater Treatment Plant
NPDES Permit: NCO037311
Forsyth County
Dear Mr. Hammonds:
Ron Boone of the Winston Salem Regional Office (WSRO) of the North Carolina Division of Water
Resources (DWR or the Division) conducted a compliance evaluation inspection of the;Creekside Manor Assisted
Living's Wastewater Treatment Plant on November 10, 2015. The assistance and cooperation of Cliff Cain, Operator
in Responsible Charge (ORC), was greatly appreciated. An inspection report is attached for your records and the
inspection findings are summarized below.
The Creekside Manor Assisted Living's Wastewater Treatment Plant is located at 6206 Reidsville Road in
Kernersville, Forsyth County, North Carolina, at approximate coordinates 36.213262 ° west, 80.0643980 north.
Creekside Manor Assisted Living is authorized to operate this 0.010 million-gallon-per-day (MGD) wastewater
treatment plant, which consists of a bar screen, an aeration basin with diffused air, a secondary clarifier, tablet
chlorination, a chlorine contact basin, tablet dechlorination, and a sludge holding tank, and discharge treated effluent
from outfall 001 of said treatment works, which is located approximately 317 feet northeast of the treatment works at
approximate coordinates 36.213770 ° West, 80.0635330 North, to an unnamed tributary of Belews Creek, which is
currently classified as Class C waters and is located in the Roanoke River Basin.
SITE REVIEW
Mr. Boone reviewed the entire plant with Mr. Cain. He seems be to doing a good job operating and
maintaining the plant. All components appeared to be in good condition and were operating as they should be. No
discrepancies or violations were noted.
DOCUMENTATION REVIEW
Mr. Cain had all required documentation for the inspection and everything,was complete and current. Mr.
Boone found no discrepancies or violations. Mr. Cain has also done a good job of documenting his operation and
maintenance of the plant.
Please keep up the good work in ensuring the Creekside Manor Assisted Living's Wastewater Treatment
Plant is properly operated and maintained and meeting all the terms and conditions of the permit. Please remember
that violations of the permit are subject to enforcement actions not to exceed $25,000 per day, per violation.
North Carolina Division of Water Resources,Winston-Salem Regional Office
Location:450 West Hanes Mill Road,Suite#300,Winston-Salem,North Carolina 27105
Phone:[phone]\FAX:[phone] Customer Service;1-877-623-6748
Internet:www.ncwaterquality.org
An Equal Opportunity\Affirmative Action Employer

If you have any questions regarding the inspection or this letter,please do not hesitate to contact Mr. Boone
or me at 336-776-9800. Thank you for your cooperation in this matter.
Sincerely,
r
4 Y.
Sherri V. Knight
Asst. Regional Supervisor
Water Quality Regional Operations
Division of Water Resources
Attachments:
1. BIMS Inspection Report
CC: Central Files
NPDES Unit
WSRO/SWP Files
R&A Labs
Attn: Cliff Cain, Operator in Responsible Charge
106 Short Street
P.O. Box 473
Kernersville, NC 27284

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 2 IF I 3 I NC0037311 I11 12 15/11/10 17 18 Ld 19 L G j 201
211111 I I I I I III 1 1I I I I I I I I I I I I I I I I I I I I III I I I I I �6
Inspection Work Days Facility Self-Monitoring Evaluation Rating B1 QA -------------------Reserved-------------
67 70 I_ 71 L] 72 I N I 73 74 751 I I I I I I 180
Section B Facility Data I—I L1J
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) 10 OOAM 15/11/10 12/03/01
Creekside Manor Assisted Living
Exit Time/Date Permit Expiration Date
6206 Reidsville Rd
11 OOAM 15/11/10 17/02/28
Kernersville NC 27284
Name(s)of Onsite Representative(s)/Titles(s)/Phone and Fax Number(s) Other Facility Data
Clifford Curtis Cain/ORC/336-996-2841/
Name,Address of Responsible Official/Title/Phone and Fax Number
Contacted
James Cheshire,6206 Reidsville Rd Kernersville NC 27284//336-996-2841/
No
Section C:Areas Evaluated During Inspection(Check only those areas evaluated)
Permit N Flow Measurement Operations&Maintenance ® Records/Reports
Self-Monitoring Program ■ Sludge Handling Disposal Facility Site Review e 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
Ron Boone WSRO WQ/l336-776-9690/
Signature of Management Q A Reviewer Agency/Office/Phone and Fax Numbers Date
EPA Form 3560-3(Rev 9-94)Previous editions are obsolete
Page# 1

. .l
NPDES yr/mo/day Inspection Type
31 NCO037311 Ill 12 15/11/10 17 18 ICI
Section D Summary of Finding/Comments(Attach additional sheets of narrative and checklists as necessary)
Please refer to the attached Inspection summary letter.
Page# 2

Permit: NCO037311 Owner-Facility: Creekside Manor Assisted Living
Inspection Date: 11/10/2015 Inspection Type: Compliance Evaluation
Permit Yes No NA NE
(If the present permit expires In 6 months or less). Has the permittee submitted a new ❑ ❑ E ❑
application?
Is the facility as described In the permit? N ❑ ❑ ❑
#Are there any special conditions for the permit? ❑ 0 ❑ ❑
Is access to the plant site restricted to the general public? E ❑ ❑ ❑
Is the inspector granted access to all areas for Inspection? ■ ❑ ❑ ❑
Comment: None
Record Keeping Yes No NA NE
Are records kept and maintained as required by the permit? 0 ❑ ❑ ❑
Is all required Information readily available, complete and current? ■ ❑ ❑ ❑
Are all records maintained for 3 years(lab reg required 5 years)? E ❑ ❑ ❑
Are analytical results consistent with data reported on DMRs? E ❑ ❑ ❑
Is the chain-of-custody completes ❑ ❑ ❑
Dates, times and location of sampling
Name of individual performing the sampling
Results of analysis and calibration M
Dates of analysis
Name of person performing analyses
Transported COCs
Are DMRs complete:do they include all permit parameters? E ❑ ❑ ❑
Has the facility submitted Its annual compliance report to users and DWQ? ❑ ❑ i ❑
(If the faclllty'ls=or>5 MGD permitted flow) Do they operate 24/7 with a certified operator ❑ S ❑ ❑
on each shift?
Is the ORC visitation log available and current? 0 ❑ ❑ ❑
Is the ORC certified at grade equal to or higher than the facility classification? 0 ❑ ❑ ❑
Is the backup operator certified at one grade less or greater than the facility classification? 0 ❑ ❑ ❑
Is a copy of the current NPDES permit available on site? E ❑ ❑ ❑
Facility has copy of previous year's Annual Report on file for review? ❑ ❑ 0 ❑
Comment: None
Laboratory Yes No NA NE
Are field parameters performed by certified personnel or laboratory? E ❑ ❑ ❑
Are all other parameters(excluding field parameters) performed by a certified lab? ❑ ❑ ❑
Page# 3

Permit: NCO037311 Owner-Facility: Creekside Manor Assisted Living
Inspection Date: 11/10/2015 Inspection Type: Compliance Evaluation
Laboratory Yes No NA NE
#Is the facility using a contract lab? ® ❑ ❑ ❑
#Is proper temperature set for sample storage(kept at less than or equal to 6.0 degrees ❑ ❑ ❑ ■
Celsius)?
Incubator(Fecal Coliform)set to 44 5 degrees Celsius+/-0 2 degrees? ❑ ❑ ❑ N
Incubator(BOD)set to 20.0 degrees Celsius+/-1.0 degrees? ❑ ❑ ❑ S
Comment: None
Effluent Sampling Yes No NA NE
Is composite sampling flow proportional? ❑ ❑ ® ❑
Is sample collected below all treatment units? ® ❑ ❑ ❑
Is proper volume collected? ® ❑ ❑ ❑
Is the tubing clean? ❑ ❑ ® ❑
#Is proper temperatureset for sample storage(kept at less than or equal to 6.0 degrees ❑ ❑ ❑
Celsius)?
Is the facility sampling performed as required by the permit(frequency, sampling type ® ❑ ❑ ❑
representative)?
Comment: None
Upstream / Downstream Sampling Yes No NA NE
Is the facility sampling performed as required by the permit(frequency,sampling type, and ❑ ❑ ❑
sampling location)?
Comment: None
Bar Screens Yes No NA NE
Type of bar screen
a.Manual
b Mechanical ❑
Are the bars adequately screening debris? ■ ❑ -E] ❑
Is the screen free of excessive debris? N ❑ ❑ ❑
Is disposal of screening in compliance? 0 ❑ ❑ ❑
Is the unit In good condition? 0 ❑ ❑ ❑
Comment: None
Aeration Basins Yes No NA NE
Page# 4

Permit: NCO037311 Owner-Facility: Creekside Manor Assisted Living
Inspection Date: 11/10/2015 Inspection Type: Compliance Evaluation
Aeration Basins Yes No NA NE
Mode of operation Ext.Air
Type of aeration system Diffused
Is the basin free of dead spots? E ❑ ❑ ❑
Are surface aerators and mixers operational? ❑ ❑ 0 ❑
Are the diffusers operational9 0 ❑ ❑ ❑
Is the foam the proper color for the treatment process? ! ❑ ❑ ❑
Does the foam cover less than 25%of the basin's surface? ■ ❑ ❑ ❑
Is the DO level acceptable? ❑ ❑ ❑ E
Is the DO level acceptable?(1 0 to 3 0 mg/1) ❑ ❑ ❑ 0
Comment: None
Secondary Clarifier Yes No NA NE
Is the clarifier free of black and odorous wastewater? ® ❑ ❑ ❑
Is the site free of excessive buildup of solids in center well of circular clarifier? ❑ ❑ ® ❑
Are weirs level? S ❑ ❑ ❑
Is the site free of weir blockage? 0 ❑ ❑ ❑
Is the site free of evidence of short-circuiting? ® ❑ ❑ ❑
Is scum removal adequate? ■ ❑ ❑ ❑
Is the site free of excessive floating sludge? N ❑ ❑ ❑
Is the drive unit operational? 0 ❑ N ❑
Is the return rate acceptable(low turbulence)? ■ ❑ ❑ ❑
Is the overflow clear of excessive solids/pin floc? N ❑ ❑ ❑
Is the sludge blanket level acceptable?(Approximately Y.of the sidewall depth) ❑ ❑ ❑ 0
Comment. None
Pumps-RAS-WAS Yes No NA NE
Are pumps in place? 0 ❑ ❑ ❑
Are pumps operational? 0 ❑ ❑ ❑
Are there adequate spare parts and supplies on site? ❑ ❑ ❑
Comment: None
Disinfection-Tablet Yes No NA NE
Are tablet chlorinators operational? 0 ❑ ❑ ❑
Page# 5

Permit: NCO037311 Owner-Faciiity: Creekside Manor Assisted Living
Inspection Date:, 11/10/2015 Inspection Type: Compliance Evaluation
Disinfection-Tablet Yes No NA NE
Are the tablets the proper size and type? 0 ❑ ❑ ❑
Number of tubes In use? 3
Is the level of chlorine residual acceptable? ❑ ❑ ❑ 0
Is the contact chamber free of growth, or sludge buildup? 0 ❑ ❑ ❑
Is there chlorine residual prior to de-chlorination? ❑ ❑ ❑ N.
Comment: None
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 ❑ ❑ ❑
Are the tablets the proper size and type? 0 ❑ ❑ ❑
Comment: None
Are tablet de-chlorinators operational? 0 ❑ ❑ ❑
Number of tubes In use? 3
Comment: None
Flow Measurement- Effluent Yes No NA NE
#Is flow meter used for reporting? 0 ❑ ❑ ❑
Is flow meter calibrated annually? 0 ❑ ❑ ❑
Is the flow meter operational? 0 ❑ ❑ ❑
(If units are separated) Does the chart recorder match the flow meter? 0 ❑ ❑ ❑
Comment: None
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: No effluent diffusers
Aerobic Digester Yes No NA NE
Is the capacity adequate? 0 ❑ ❑ ❑
Page# 6

Permit: NCO037311 Owner-Facility: Creekside Manor Assisted Living
Inspection Date: 11/10/2015 Inspection Type: Compliance Evaluation
Aerobic Digester Yes No NA NE
Is the mixing adequate? N ❑ ❑ ❑
Is the site free of excessive foaming in the tank? 0 ❑ ❑ ❑
#Is the odor acceptable? 0 ❑ ❑ ❑
#Is tankage available for properly waste sludge? E ❑ ❑ ❑
Comment: None
Operations & Maintenance Yes No NA NE
Is the plant generally clean with acceptable housekeeping? ■ ❑ ❑ ❑
Does the facility analyze process control parameters, for ex MLSS, MCRT, Settleable ® ❑ ❑ ❑
Solids, pH, DO, Sludge Judge, and other that are applicable?
Comment. None
Page# 7