NC0070033_Fact Sheet_20190619

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FACT SHEET FOR EXPEDITED PERMIT RENEWALS
This form must be completed by Permit Writers for all expedited permits which do not require
full Fact Sheets. Expedited permits are generally simple 100% domestics (e.g., schools, mobile
home parks, etc) that can be administratively renewed with minor changes, but can include
facilities with more complex issues (Special Conditions, 303(d) listed water, toxicity testing,
instream monitoring, compliance concerns).
Basic Information for Expedited Permit Renewals
Permit Writer / Date
Sydney Carpenter 6/19/2019
Permit Number
NCO070033
Facility Name / Facility Class
Quail Run Mobile Home Park WWTP / WW-
1
Basin Name / Sub -basin number
Yadkin Pee -Dee / 03-07-04
Receiving Stream / HUC
Miller Creek / 0304010113
Stream Classification in Permit
C / Index: 12-94-14
Does permit need Daily Max NH3 limits?
No — already resent
Does permit need TRC limits/language?
No — already resent
Does permit have toxicity testing?
No
Does permit have Special Conditions?
No
Does permit have instream monitoring?
Dissolved Oxygen and Temperature
Is the stream impair d on 303 d list)?
No
Any obvious compliance concerns?
No enforcement cases, but multiple NOVs for
Fecal Coliform limit, at least one every year
since 2014 renewal. Couple of TRC frequency
violations at end of 2018.
Any permit modifications since lastpermit?
None.
New expiration date
5/31/2024
Comments on Draft Permit
➢ Updated parameter codes.
➢ Added regulatory citations.
➢ Updated eDMR footnote and Section
A. 3
Changes to Final?
➢ None

DocuSign Envelope ID: 0323BD3E-94C2-4082-B842-4CD02F2B53DC
ROY COOPED NORTH CAROLINA
Governor Environmental Quaifly
lUCHAEL S- REGAN
Sacretm:
LES DA Ci rLPEPPER
Interfnr Director
January 08, 2019
Rodney Sides
Frog Level Industries Inc
PO Box 208
Lewisville, NC 27023-0208
Subject: Permit Renewal
Application No. NCO070033
Quail Run Mobile Home Park
Davidson County
Dear Applicant:
The Water Quality Permitting Section acknowledges the December 21, 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. 15OB-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.
ec: WQPS Laserfiche File w/application
Sincerely,
j�4A6
Wren Thedford
Administrative Assistant
Water Quality Permitting Section
rwn� :,a�cxi.a� D E Q—�
oep*iReni n [n+uo.anw W Wry
North Carolina Department of Environmental Quality I Division of Water Resources
1617 Mail Service Center I Raleigh, North Carolina 27699-1617
919-807-6300

DocuSign Envelope ID: 0323BD3E-94C2-4082-B842-4CD02F2B53DC
Frog Level Industries, Inc.
2559 West Clemmonsville Road
Winston-Salem, NC 27127
Mailing Address:
PO Box 208
Lewisville, NC 27023
December 14, 2018
Wren Thedford
NC DENR / DWR / NPDES Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
NPDES Permit Renewal for Quail Run Mobile Home Park
Mr. Thedford,
Please find attach our completed NPDES Application — Form D for Quail Run Mobile
Home Park and a brief narrative on sludge management. There have been no changes to
the system over the past 5 years. Please let me know if you need any additional
information.
Sincerely,
(4 (zl-a'
Rodney R. Sides
Owner

DocuSign Envelope ID: 0323BD3E-94C2-4082-B842-4CD02F2B53DC
NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
Mail the complete application to:
NC DEQ / DWR / NPDES
1617 Mail Service Center, Raleigh, NC 27699-1617
NPDES Permit 000070033
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
Frog Level Industries Inc.
Facility Name
Quail Run Mobile Home Park
Mailing Address
PO Box 208
City
Lewisville
State / Zip Code
North Carolina, 27023
Telephone Number
[phone]
Fax Number
( )
e-mail Address
[e-mail]
2. Location of facility producing discharge:
Check here if same address as above ❑
Street Address or State Road 136 Quail Place Drive
City Winston-Salem
State / Zip Code NC, 27127
County Davidson
3. Operator Information:
Name of the firm, public organization or other entity that operates the facility. (Note that this is not
referring to the Operator in Responsible Charge or ORC)
Name Luther Leonard
Mailing Address 502 Northside Drive
City Lexington
State / Zip Code NC, 27295 J
Telephone Number [phone]
Fax Number ( )
e-mail Address [e-mail]
I
1 of 3 Form-D 6/2017

DocuSign Envelope ID: 0323BD3E-94C2-4082-B842-4CD02F2B53DC
a
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
X
Number of Homes 45
School
❑
Number of Students/Staff
Other
❑
Explain:
Describe the source(s) of wastewater (example: subdivision, mobile home park, shopping centers,
restaurants, etc.):
Mobile Home Park
Number of persons served: 180
S. Type of collection system
X Separate (sanitary sewer only) ❑ Combined (storm sewer and sanitary sewer)
6. Outfall Information:
Number of separate discharge points 1
Outfall Identification number(s) Outfall 1
Is the outfall equipped with a diffuser? ❑ Yes X No
?. Name of receiving streams) ( W applicants: Provide a map showing the exact location of each
outfall�
Miller Creek, currently classified C waters in subbasin 03-07-04 of the Yadkin -Pee Dee River Bas
S. Frequency of Discharge: X 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.
• Two 3,200 gallon septic tanks
• 4,000 gallon septic tank
• Two 4,500 gallon septic tanks
• 8,400 gallon re -circulating dosing tank
• 4,250 square ft recirculating surface sand filter
• Tablet chlorinator
• 350 gallon chlorine contact tank
2 of 3 Form-D 6/2017

DocuSign Envelope ID: 0323BD3E-94C2-4082-B842-4CD02F2B53DC
NPDES APPLICATION - FORM D
For privately -owned treatment systems treating 100% domestic wastewaters <1.0 MGD
10. Flow Information:
Treatment Plant Design flow .017 MGD
Annual Average daily flow .0034 MGD (for the previous 3 years)
Maximum daily flow .0039 MGD (for the previous 3 years)
11. Is this facility located on Indian country?
❑ Yes X No
12. Effluent Data
NEW APPLICANTS: Provide data for the parameters listed. Fecal Colifonn, 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 parameters currently in your permit. Mark other parameters "N/A".
Parameter
Daily
Maximum
Monthly
Average
Units of
Measurement
Biochemical Oxygen Demand (BOD5)
18.7
7.8
MG/L
Fecal Coliform
19.4
1.82
#/ 100ML
Total Suspended Solids
13.6
5.8
MG/L
Temperature (Summer)
25
22.5
C
Temperature (Winter)
20
14.5
C
pH
6.8
6.6
Units
13. List all permits, construction approvals and/or applications:
Type Permit Number Type
Hazardous Waste (RCRA)
UIC (SDWA)
NPDES NCO070033
PSD (CAA)
Non -attainment program (CAA)
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.
Rodney R Sides Owner
Printed name of Perpon Signing Title
/2-`Y k4'
of ADplicant 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

DocuSign Envelope ID: 0323BD3E-94C2-4082-B842-4CD02F2B53DC
Frog Level Industries, Inc.
Quail Run Mobile Home Park
Sludge Management Plan
As part of the waste management system for the mobile home park, we utilize 5 septic tanks to collect
the solids. Those tanks are pumped on a quarterly basis by an independent septic hauler on a quarterly
basis. These solids are then taken to the municipal waste water treatment plant for disposal.

DocuSign Envelope ID: 0323BD3E-94C2-4082-B842-4CD02F2B53DC
42008646
AFFIDAVIT OF PUBLICATION
J000642985
STATE OF NORTH CAROLWA
DAVIDSON COUNTY LEXINGTON, NC Ma 8
Y 2019
I, Lynn Bowers OF THE DISPATCH, A NEWSPAPER PUBLISHED fN THE CITY OF LEXIN
AFORESAID, BEING DULY SWORN, SAYS THE FOREGOING LEGAL OF WHICH THE A TTACHED IS A TRUE COPY,
WAS PUBLISHED IN SAID NEWSPAPER ONCE, BEGINNING THE 8th DAY OF Ma 201 GTON, COUNTY AND STATE
PUBLICATION FEE: $ 132.Q9 Y, 9.
421M_� (SEAL)
S TO AND SUBSCRIS D BEFORE ME, THIS
DAY OF
MY COMMISSION EXPIRES
Ad Copy:
Public Notice
N trth caroltna
Environmental Mana ement
Commission/NPDES Unit
16t7 Mlail Service Center
Raleigh, NC 27ti99 1617
Notice of intent to jssue'a
NPDES Wastewater Permit
The North Carolina
Environmental Management
Commission proposes to issue
a NPDES wastewater
discharge permit to the
Person(s) listed below. Written
comments regarding the
Proposed permit will be
accepted until 30 days after the
Publish date of this notice. The
Director of the NC Division of
Water Resources (DWR) may
hold a Public hearing should
there be a significant degree of
Public interest. Please mail
comments and/or information
requests to DWR at the above
address. interested persons
may visit the DWR at 512 N.
Salisbury Street, Raleigh, NC
to review information on file.
Additional information on
NPDES permits and this notice
nay be found on our website:
rtt tilde .nc, ov/about/div.....
Jwate r-resources/water-
esaurces- ermits/wastewater-
-ranch/nodes-
calling [phone]. Kurz
Transfer Products,
requested renewal of L. P.
NC0070637/Kurt Permit
Products Transfer
on
County. Facility dischargesDavidto
Reedy Creek/Yadkin-Pee Dee
River Basin. Currently, Total
Residual Chlorine is water
quality limited, NCO059536:
Hilltop Living Center requested
renewal of permit for the Hilltop
Living Center WWTP:
Davidson County. This
permitted
o aan iutreated
wastewater tunnamed
tributary to the Yadkin River;
Yadkin -Pee Dee River Basin.
Currently, BOD, Ammonia -
Nitrogen, MBAS and Total
Residual Chlorine are water
quality limited. Fred P. Cox
requested renewal of NPDES
permit NC0070033/(wail Run
Mobile Home Park
WNTP/Davidson County.
Facility discharges to Miller
Croek/Yadkin-Fee Dee River
Basin. Currently ammonia
nitrogen, total residual chlorine,
and fecal celiform are water
quality limited.
May 8, 2019
OyN I L tAf k'
Notafy Public
Davidson County
iu1y Commission Expires=
O ��
+CIA"Rd-.
astewater/oublic notices.or by