NC0030139_Renewal Application_20180131

Water Resources
ENViRONNEIAfrAL OUAI.ITY
January 31, 2018
Renita Chapman
White Oak Manor
188 Oscar Justice Rd
Rutherfordton, NC 28139
Subject: Permit Renewal
Application No. NCO030139
White Oak Manor- Rutherfordton
Rutherford County
Dear Applicant:
ROY COOPER
C"iatia"W
MICHAEL S- REGAN
LD qDA CULPEPPER
lidephn Director
The Water Quality Permitting Section acknowledges the January 31, 2018 receipt of your permit renewal application and
supporting documentation. Your application will be assigned to a permit writer within the Section's NPDES WW
permitting branch. Per G.S. 150B-3 your current permit does not expire until permit decision on the application is made.
Continuation of the current permit is contingent on timely and sufficient application for renewal of the current permit.
The permit writer will contact you if additional information is required to complete your permit renewal. Please respond
in a timely manner to requests for additional information necessary to allow a complete review of the application and
renewal of the permit.
Information regarding the status of your renewal application can be found online using the Department of Environmental
Quality's Environmental Application Tracker at:
https•//deq nc gov/permits-regulations/permit-guidance/environmental-application-tracker
If you have any additional questions about the permit, please contact the primary reviewer of the application using the
links available within the Application Tracker.
Sincerely,
�ro'1,"'
Wren Thedford
Administrative Assistant
Water Quality Permitting Section
cc: Central Files w/application(ARO)
ec: WQPS Laserfiche File w/application
State of North Carolina I Environmental Quality I Water Resources
1617 Mail Service Center I Raleigh, North Carolina 27699-1617
919-807-6300

Water Quality Lab & Operations, Inc.
P.O. Box 1167/ 1522 Tynecastle Highway
Banner Elk, NC 28604 RECEIVE®/DENR/DWR
Ph. 828-898-6277 Fax [phone]
January 24, 2018 JAN 201$
Water Resources
Ms. Emily Phillips, Environmental Specialist Permitting Section
NCDEQ/DWR/Coinpliance and Expedited Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
Via E-mail to [e-mail]
Re: White Oak Manor — Rutherfordton WWTP NPDES NC0030139
Dear Ms. Phillips:
Please find enclosed an application for the permit renewal for White Oak Manor,
Rutherfordton WWTP. All items on the checklist are included with the permit renewal.
There have been no significant changes to the facility since the previous permit cycle.
Please note that the maintenance director for the facility, Mike Pcemcni has signed the
Delegation Letter and permission forms for the permit; Ms. Chapman, the Administrator,
is out of the office until after the permit submission deadline.
If we can be of further assistance, please do not hesitate to contact us.
Signatory Authority

JAN/24/2018/WED 01;59 PM FAX No, P. 003
JAN/24/2018/WED 10-54 AM FAX No, P.002
Tanuary 16, 2018
Wastewatez Branch
Water Quality permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Delegation of Signature .Authox�ty
Vft ite Oak Manor - Ratherfordton
�\TDES Number NCO030139
To Whom It May Concenoc
By notice of this letter, I hereby delegate signatory authority to each of the following
individuals for all permit applications, discharge mob itozi ng reports, and other
ivaformation zelating to the operations at the subject facility as required by all applicable
federal, state, aad local environmental agencies spmificallywith the requirements for
signatory authority as specified in 15A NCAC 2B.0506.
Jadd Brewer
Operations Mailer
P.O. BoX 1167
1522 Tynecastle Hwy Banner Elk, NC 28604
[e-mail]
828-898-6277
828-260-2027
If you have any questions regarding this letter, please feel free to contact me.
Sincerely, /� r
7 7 - ---
MI KE PGEN/G 4-( M+`(/A/7-, 01R.
cc: Asheville Regio:ual office, Water Quality Permitting Section

NPDES APPLICATION - FORM D
For privately-owned treatment systems treating 100% domestic wastewaters <1.0 MGD
Mail the complete application to:
N. C. DEQ / DWR / NPDES
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit C0030139
If you are completing this form in computer use the TAB key or the up — down arrows to move 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
Renata Chapman
Facility Name
White Oak Manor- Rutherfordton WWTP
Mailing Address
188 Oscar Justice Road
City
Rutherfordton
State / Zip Code
NC 28139
Telephone Number
[phone]
Fax Number
[phone]
e-mail Address
[e-mail]
2. Location of facility producing discharge:
Check here if same address as above
Street Address or State Road
City
State / Zip Code
County
3. Operator Information:
Name of the firm, public organization or other entity that operates the facility. (Note that this is not
refemng to the Operator in Responsible Charge or ORQ
Name Water Quality Lab and Operations, Inc.
Mailing Address P.O. Box 1167
City Banner Elk
State / Zip Code NC 28604
Telephone Number [phone]
Fax Number [phone]
e-mail Address [e-mail]
1 of 3 Form -D 612017

t� JAN/24/2018AED 02:00 PM FAX No. P 004
JAN,124/2018/WED 10 54 AM FAX No. P. 003
Water Quality Lab & Operations, Inc.
P.O. Box 1167/ 1522 Tynecastle Highway
Banner Elk, NC 23604
Ph. 828-898-6277 Fax [phone]
L the undersigned, do hereby give mypamission and grant my authority as the
/7&ia1L1VAA14 Q M , of White Oak Manor, Rutherfordton, to Jadd Brewer, Co-
Owner/Operator of Water Quality Lab and Operations, Jhc. to complete, sign and submit
the Wastewater Permit Renewal Application for White Oak Manor - Rutherfordton for
2018.
This is the g Al day of _ -TfiN u.9P K , 2018.
Painted Name and Title: /L/ 1g /0G£n/ jG rV /A//UT_ A/ K,
Signature: Q� J

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 143
Residential
❑
Number of Homes
School
❑
Number of Students/Staff
Other
®
Explain: 80
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Nursing Center providing long term care as well as short term rehabilitation
The facility has 80 beds; population of residents may vary
Number of persons served: 223
S. Type of collection system
® Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points 1
Outfall Identification number(s) 001
Is the outfall equipped with a diffuser? ❑ Yes ® No
7. Name of receiving stream(s) (NEW applicants: Provide a map showing the exact location of each
outfalls
Unnamed tributary to Catheys Creek, classified Class WS -V waters, Broad River Basin
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
Equalization basin
Aeration basin
Clarifier
Chlorine Contact Chamber
Dechlorination
2 of 3 Form -D 612017

NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow .015 MGD
Annual Average daily flow .0099 MGD (for the previous 3 years)
Maximum daily flow 0.088 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes ® No
12. Effluent Data
NEW APPLICANTS: Provide data for the 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. ;fonly one analysis is reported, report as daily maximum
REANWAL APPLICANTS: Provide the highest single reading (Daily Maximum) and Monthly Average over
the past 36 months for parameters currently in your permit. Mark other parameters "N/A'.
Parameter
Daily
Maximum
Monthly
Average
Units of
Measurement
Biochemical Oxygen Demand (BODS)
43.7
25
mg/L
Fecal Coliform
6000
35
cuf/ 100mL
Total Suspended Solids
45
29.8
mg/L
Temperature (Summer)
33
32
Degrees Celcius
Temperature (Wmter)
25
22
Degrees Celcius
pH
8.8
81
s/u
13. List all permits, construction approvals and/or applications:
Type Permit Number Type
Hazardous Waste (RCRA)
UIC (SDWA)
NPDES
PSD (CAA)
Non-attamment program (CAA)
NCO030139
14. APPLICANT CERTIFICATION
NESHAPS (CAA)
Ocean Dumping (MPRSA)
Dredge or fill (Section 404 or CWA)
Other
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.
Jadd Brewer Signatory
Printed name of Person Signing Title
of Applicant
Date
'North Carolina General Statute 143-215.6 (b)(2) states, Any person who knowingly 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 inaccurate 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 similar offense.)
3 of 3 Form -D 6/2017

Water Quality Lab & Operations, Inc.
P.O. Box 1167/ 1522 Tynecastle Highway
Banner Elk, NC 28604
Ph. 828-898-6277 Fax [phone]
WHITE OAK MANOR RUTHERFORDON WWTP SLUDGE MANAGEMENT
Sludge is managed via a commercial hauler, Harris Septic Tank Services, 1103 US -
74 BUS, Ellenboro, NC 28040.