NCG550250_Report (septic pumping)_20211123

Date
Time:
Winston-Salem/Forsyth County
City/County Utilities
Septage Service Record
81212
Please complete a septage service record for each load discharged. List each customer's
information that comprises the total load to be discharged. Septage from Forsyth County
and adjacent counties will be accepted for treatment. Elledge WWTP is open Monday -Friday.
6 A.M.-6 P.M. For emergencies, please call 659-4322.
Septa a originates from:
1)
2) \ r , ;" i /"��
ame' f)property own
11
l — 11
Location where septage was pumped
3)
Location where septage was pumped
Name of property owner
Location where septage was pumped
Hauler Information:4
Septage pumped by:
Name of Septage Management Fir
Gallons of Septage di
i.-
Phone number
Date
I
Phone number
Date
Phone number
Date
"I certify that the above information is correct, to the best of my knowledge. and that the materials
described above are not subject to Federal Regulations as hazardous waste. I agree to abide by
all conditions set forth in the City of Winston-Salem's Sewage System Policy and failure to comply
may result in a penalty of up to twenty-five thousand dollars ($25,000) per day, per violation and
loss of privilege to dispose of septage at the City's receiving station. I also agree that all records and
equipment used in servicing of septage tanks is subject to inspection at any time by the City of
Winston-Salem, Utilities Departrpe1t personnel. —
Signature (Septage pumper)
Date
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