NCS01162_Permit2019_Initial

2019
Permit and Registration
A & D Environmental
is hereby issued a Septage Management Firm Permit, Permit Number NCS-01162
And by virtue of completing the annual training
requirements is hereby registered as a Septage Management Firm
in the State of North Carolina.
This permit to operate a Septage Management Firm is issued to the above named person, business or entity alone and is not transferable to any other person, business or entity. Firm operation shall be in accordance with the provisions of N.C. General Statute 130A-291.1 - 130A-291.3, Title 15A of the N.C. Administrative Code 13B .0800 et.seq.,
conditions of the permit, and representations made in the application and accompanying documents for a permit.
The permit holder is authorized to discharge septage only at the locations(s) listed below:
1.Septage Detention or Treatment Facility SDTF-34-02
2.Waste Management, Great Oak Landfill, Randleman NC
This permit does not entitle the permit holder to operate a Septage Land Application Site, a Septage Detention or Treatment Facility, or any other solid waste management facility not specified herein.
Failure to operate as permitted may result in the Department suspending or revoking this permit, initiating action to enjoin the unpermitted operation, imposing administrative penalties, or invoking any other remedy as provided in Chapter 130A, Article 1, part 2 of the North Carolina General Statutes. This permit and registration expires on December 31, 2019.
__________________________________________________ Adam Ulishney, Environmental Compliance Branch Head
State of North Carolina
Environmental Quality
Waste Management
Application for Permit to Operate a
Septage Management Firm
For questions regarding this form or the online application process, please contact Jeffrey Bullard (919-707-8285) or Chester Cobb (919-
707-8283).
Firm name**
Septage Management Firm permit number (NCS #)**
Street address of office**
County**
Mailing address same as street address of office?**
Phone**Fax
Email**
Firm owner's name**
Mailing address same as street address of office?**
Phone**Fax
Firm operator's name**Firm operator's title
Mailing address same as street address of office?**
Phone**Fax
Firm Info
A&D Environmental
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-01162
Enter the five digits following the NCS #
City
Archdale
State / Province / Region
NC
Postal / Zip Code
27263
Country
United States
Street Address
2718 Uwharrie Rd
Address Line 2
Randolph
Yes No
3364347750 3364347752
[e-mail]
Owner Info
A&D Holdings, Inc.
Yes No
3364347750 3364347752
Operator Info
Travis Clapp Resource Manager
Yes No
3364347750 3364347752
Amount in gallons*
DomesticDomestic
Portable Toilet WastePortable Toilet Waste
Grease (Restaurant)Grease (Restaurant)
Treatment PlantTreatment Plant
Industrial/CommercialIndustrial/Commercial
List each county you plan to do business in:**
Do you plan to operate pumper vehicles?**
"I certify, under penalty of law, that the pumper vehicle or vehicles listed in the submitted permit application meets the requirements for safe
and sanitary transportation of septage as required by 15A NCAC 13B .0844(a) and vehicle lettering as required by 15A NCAC .0844(b).
Furthermore, I also certify that a log is maintained of each septage pumping event as required by 15A NCAC 13B .0839(a). I am aware that
there significant penalties for false certification including the possibility of fine and imprisonment."
Signature
Date**
Title**
Choose how to add vehicle descriptions**
Pumper Vehicles
Usage*License Tag #*Vehicle Identification #*Tank Capacity*
Approved wastewater treatment plant**
Septage Land Application Sites (SLAS)**
Type and amount of septage pumped in the last 12 months
0
0
1,277
0
6,100
North Carolina counties of operation
All counties
Vehicle Info
Yes No
9/27/2019
Fleet Manager
Add vehicles
individually
Upload List
Grease (restaurant)LX-4550 (NC)4V5KC9GH34N350120 3,500
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Yes No
Yes No
Septage Detention or Treatment Facility (SDTF)**
If you are not the permit holder for the septage detention/treatment facility, you must have a signed detention/treatment authorization form for
each site.
SDTF #*Expiration Date*Authorization
Other disposal method**
Description*Authorization
Date**Hours**
Location**
Training Sponsored or Provided by**
Date Hours
Location
Training Sponsored or Provided by
Select one**
Comments or notes
Yes No
SDTF-34-04 12/31/2019 SDTF
Authorization
Form
2019_AD.pdf
69.52KB
Yes No
Solidified Material sent to Landfill 2019
Acceptance
Letter -
A_D.pdf
137.67…
Septage Management Firm Operator Training Completed
12/8/2018 4
Raleigh, NC
NC Pumper Group & NC Portable Toilet Group
Septage Land Application Site Operator Training Completed
0
Registration Type
Registered Portable Sanitation Firm
Registered Septage Management Firm
Registered Portable Sanitation and Septage Management Firm
Comments and Notes
Signature
Date
Print Name**Title**
Certification Statement
I certify that the information and representations in this application for a permit are true, complete, and accurate to the best of my knowledge and belief. I am
aware that a permit may be suspended or revoked upon a finding that its issuance was based upon incorrect or inadequate information that materially affected
the decision to issue the permit and that there are criminal penalties for knowingly making a false statement, representation, or certification.
9/27/2019
02:00:00 PM
Paul A. Butsavage VP, Remediation and Waste Management

September 25, 2019

Mr. Paul Butsavage
A&D Environmental Services
1741 Calks Ferry Road
Lexington, SC 29073
[phone]

RE: Acceptance of Solidification Process Waste – Biological Sludge

Dear Mr. Butsavage:

The Great Oak Landfill is a permitted Subtitle D landfill located in Randleman, NC. As
such, the facility is prepared to accept the referenced waste stream. All special waste
disposed at the landfill is subject to profiling and may require analytical data submission
prior to acceptance. Sludges, filter cake, and filter media are subject to a standard paint
filter test to assure the absence of free liquids.

The landfill will accept the waste generated by wastewater treatment facilities and
processed by A&D Environmental as described in the approved profile #100597NC. This
acceptance is contingent on the waste stream’s consistency with prior approval, agreement
of both parties as to cost and charges to be determined at a later date. Any changes or
deviations in the waste may require separate approval.

If additional information is required, please feel free to contact me at [phone] or at
[e-mail].

Sincerely,
Richland Landfill

Jason McRee
Industrial Account Manager

AUTHORIZATION TO DISCHARGE SEPTAGE AT A SEPTAGE TREATMENT OR
STORAGE FACILITY PERMITTED TO SOMEONE OTHER THAN YOURSELF
(This form is used by a detention or treatment facility permit holder to indicate that permission has been given to a permitted
Septage Management Firm to discharge septage into the permit holders detention or treatment facility.)

I, Rodney Sides (Environmental Relief Technology, Inc.
(Facility Operator)

617 Waughtown Street, Building 350, Winston-Salem NC 27107 (Operator Address)

do hereby authorize: Travis Clapp
(Owner of Septage Management Firm)

A&D Environmental NCS # 01162
(Name of Septage Management Firm)

PO Box 484 High Point, NC 27261
(Address of Septage Management Firm)

to utilize septage detention or treatment facility # 34-02 for the treatment or storage of septage *

in 2019 . The facility will be operated in accordance with the Septage Management Rules **.

Date: 12/1/18 Signed (Facility Operator)

* As defined in G.S. 130A-290(a)(32)
** As defined in 15A NCAC 13B .0800

Return the properly completed form to:
North Carolina Department of Environment and Natural Resources
Division of Waste Management
Solid Waste Section
1646 Mail Service Center
Raleigh, NC 27699-1646

DENR-OC3
09/2/15 DEPARTMENT OF ENVIRONMENTAL QUALITY
CASH RECEIPTS JOURNAL VOUCHER WITH SUMMARY Page_of_
DOCUMENT ID: I 1621 I
APP. CODE: D
DIVISION WASTE MANAGEMENT
OFFICE Line I COMPANY II USE No. ACCOUNT
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GL EFFECTIVE DATE: [ DATA TYPE CODE: GJ ICENTER AMOUNT
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Budget Code: 14300
Deposit No.: I :: ACCT LINE DESCRIPTION RULE
275.00 I LATE FEE
Randolph
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DENR-OC3
09/2/15 DEPARTMENT OF ENVIRONMENTAL QUALITY
CASH RECEIPTS JOURNAL VOUCHER WITH SUMMARY Page_of_
DOCUMENT ID: I 1621 l
APP. CODE: D
DIVISION WASTE MANAGEMENT
OFFICE EJ□I II USE COMPANY : ACCOUNT
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GL EFFECTIVE DATE:
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