NC0037311_Renewal (Application)_20161116

RESEARch & ANA[Y ICA[
LAbORATORIES, INC.
Analytical/Process Consultations
16 November 2016
Mr. William Hammonds
Creekside Manor Rest Home
P.O. Box 1487
Kernersville, NC 27285
Subject: NPDES Permit NCO037311 Renewal Application Report
Dear Mr. Hammonds:
Enclosed is one (1) copy of the NPDES Permit Application: Form D requesting
renewal of NPDES Permit No. NC 0037311. There have been no significant changes to
the wastewater treatment facility. Please review and let me know if you would like RAL to
sign as your authorized agent with submittal to DENR.
If you should have any questions concerning this application renewal please so
advise.
Sincerely,
James M. Cheshire
President CEO
Research & Analytical Laboratories, Inc.
JMC/jm
Q
P.O. Box 473. 106 Short Street • Kernersvdle, North Carolina 27284.336-996-2841 • Fax [phone]
www.randalabs.com

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating l00% domestic wastewaters <i.o MGD
Mail the complete application to:
N. C. DFJIR / Division of Water Quality / NPDZ8 Unit
1617 Mail Service Center, Raleigh, NC 27699-1617
N DES Permit WC003731 i
If you are completing this form in computer use the TAB key or the up - doum arrows to moue from one
field to the next: To check the boxes, click your mouse on top of the box. Otherwise, please print or type.
1. Contact Information:
Owner Name
Hammond Properties
Facility Name
Creekside Manor Rest Home
Mailing Address
P.O. Box 1487
City
Kernersville
State / Zip Code
NC/27285
Telephone Number
[phone]
Fax Number
[phone]
e-mail Address
whammondsRaol.com
2. Location of facility producing discharge:
Check here if same address as above ❑
Street Address or State Road 6206 Reidsville Rd.
City
Kernersville
State / Zip Code
NC/27285
County
Forsyth
3. Operator Information:
Name of the JbM public organization or other entity that operates the facility. (Note that this is not
referring to the Operator in Responsible Charge or ORC)
Name Research & Analytical Laboratories, Inc
Mailing Address
P. O. Lox 473
City
Kernersville
State / Zip Code
NC/27284
Telephone Number
[phone]
Fax Number
[phone]
e-mail Address
[e-mail]
1 d3
FOMI D 11/12

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
4. Description of wastewater:
Facility Generating_ Wastewater(check all that applyr
Industrial
❑
Number of Employees
Commercial
❑
Number of Employees
Residential
❑
Number of Homes
School
❑
Number of Students/Staff
Other
®
Explain: Rmthome
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Number of persons served: 60
S. Type of collection system
® Separate (sanitary sewer only)
6. Outfall Information:
❑ Combined (storm sewer and sanitary sewer)
Number of separate discharge points 1
Outfall Identification number(s) 001
Is the outfall equipped with a diffuser? ❑ Yes ® No
7. Name of receiving streams) (NEW ap
outfall): plicants: Provide a map showing the exact location of each
Unnamed tributary to Belews Creek
S. Frequency of Discharge: ® Continuous ❑ Intermittent
If intermittent:
Days per week discharge occurs: Duration:
9. Describe the treatment system
List all installed components, including capacities, provide design removal for BOD, TSS, nitrogen and
phosphorus. If the space provided is not sufficient, attach the description of the treatment system in a
separate sheet of paper.
0.01 wastewater facility consisting of the following:
-Bar screen
-aeration basin with diffused air
-Secondary Clarifier
-tablet chlorination
-chlorine contact basin
-sludge holding tank
2 of 3 FOWD 11/12

1 �
NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 1000/6 domestic wastewaters <1.0 MOD
10. Flow Information:
Treatment Plant Design flow
Annual Average daily flow
Maximum daily now
(for the previous 3 years)
(for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes ®No
12. Effluent Data
NEW APPLICANTS: Provide data for fire parameters listed. Fecal Coliform, Temperature and pH shall be grab
samples, for all other parameters 24-hour composite sampling shall be used. If more than one analysis is reported,
report daily maximum and monthly average. If only one analysis is reported, report as daily maximum.
RENEWAL APPLICANTS: Provide,, the highest single reading (Daily Maximum) and Monthly Average
over the past 36 months for vararnke7rs ndu in our it: Mark otherammeter. N A'
s p
Parameter
Daily
Maximum
Monthly
Averaxe
Units of
measurement
Biochemical Oxygen Demand (BODS)
40
13.9
mg/L
Fecal Coliform
4000
2.96
col/ 100 mis
Total Suspended Solids
67.3
18.1
mg/L
Temperature (Summer) j
30
23.36
°C
Temperature (Winter) I
21
13.16
°C
pH I
8.3
N/A
Standard Units
I
13. List all permits, construction approvals and/or applications:
Type Pe Irmit Number Type
Hazardous Waste (RCRA) I NESHAPS (CAA)
UIC (SDWA) Ocean Dumping (MPRSA)
NPDES NCO037311 Dredge or fill (Section 404 or CWA)
PSD (CAA) I Other
Non -attainment program (CAA) f
14. APPLICANT
Permit Number
I certify that I am familiar with the information contained in the application and that to the
best of my knowledge and belief such information is true, complete, and accurate.
Printed name of Person
Of
Title
Date
Nbrth Carolina General Statute 143-215.6 (b)(2) states: Any person who Imowlngly makes any false statement representation, or certification In any
application, record, report, plan, or other document files or required to be maintained under Article 21 or regulations of the Environmental Management
Commission Implementing that Article, or who falsifies, tampers with, or knowingly renders Inaxurate any recording or monitoring device or method
required to be operated or maintained under Article 21 or regulations of the Environmental Management Commission implementing that Article, shall be
guilty of a misdemeanor punishable by a fine not to exceed $25,000, or by Imprisonment not to exceed six months, or by both. (18 U.S.C. Section 1001
provides a punishment by a fine of not more than $25,000 or imprisonment not more than 5 years, or both, for a simllar offense.)
3of3
Forrn-D 11!12
1

Sludge Management Plan
Creekside Manor Rest Home WWTP
NPDES Permit No. NC 0037311
Sludge from the Creekside Manor Rest Home wastewater treatment plant are disposed of in the
following manner.
Solids are collected in the sludge holding tank and digested aerobically. The excess solids
are periodically pumped and hauled by Carolina Septic a licensed septic pumper contractor
and disposed of at the City of Greensboro wateiwater treatment plant.