NCS01441_2019Permit_Initial

2019
Permit and Registration

Lee Septic & Land
is hereby issued a Septage Management Firm Permit, Permit Number NCS-01441
And by virtue of completing the annual training
requirements is hereby registered as a Portable Sanitation &
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. Elizabeth City WWTP
2. Septage Detention or Treatment Facilities, SDTF-27-24 and SDTF-27-22
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
Lee Septic & Land
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-01441
Enter the five digits following the NCS #
City
Kitty Hawk
State / Province / Region
NC
Postal / Zip Code
27949
Country
United States
Street Address
3908 Poor Ridge Road
Address Line 2
Dare
Yes No
2522613073
[e-mail]
Owner Info
Roy L Etheridge
Yes No
2522028651
Operator Info
Roy L Etheridge Owner
Yes No
2522028651
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
94,750
0
0
0
0
North Carolina counties of operation
Dare
Currituck
Vehicle Info
Yes No
8/23/2019
Owner
Add vehicles
individually
Upload List
Domestic Septage YA141448 1FVHA6CV46LW64565 4,200
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Yes No
If you are not the permit holder for the septage land application site, you must have a signed land application authorization form for each
site.
SLAS #*Expiration Date*Authorization
Septage Detention or Treatment Facility (SDTF)**
Other disposal method**
Date**Hours**
Location**
Training Sponsored or Provided by**
Date Hours
Location
Training Sponsored or Provided by
Select one**
Comments or notes
Signature
Date
Yes No
SLAS-27-06 8/13/2019
Yes No
Yes No
Septage Management Firm Operator Training Completed
5/13/2019 6
Jeanettes Pier
NC Septic Tank Association
Septage Land Application Site Operator Training Completed
5/13/2019 3
Jeanettes Pier
NC Septic Tank Association
Registration Type
Registered Portable Sanitation Firm
Registered Septage Management Firm
Registered Portable Sanitation and Septage Management Firm
Comments and Notes
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.
8/23/2019
Print Name**Title**
8/23/2019
10:34:33 AM
Roy L Etheridge Owner
AUTHORIZATION TO DISCHARGE SEPTAGE TO A WASTEWATER TREATMENT FACILITY
North Carolina Department of Environmental Quality
Division of Waste Management -Solid Waste Section
1646 Mail Service Center,Raleigh,NC27699-1646
Fee assessments and waste determinations will be required at the discretion of the wastewater
treatment facility.The facility has the ultimate prerogative to deny discharges of any wastes to the
incoming wastewater stream.
1,R_e_b_e_c_c__a__M_i_l_l_e_r 1_0_°_6_3_8_5 E__l_i_z_a_b_e_t_h__C_l_'t_y~_W_W_T_P _
(Plant Operator in Responsible Charge (ORC),ORC License Number,Name of Plant)
PO Box 347,Elizabeth City,NC 27909
(Address)
_{_2_5_2_)__3_3__7_-_6_6_2_6 do hereby authorize R__o=.,y__L_e_e__E_t_h_e_r__i_d..:::g_e....:..,__J_r_._
(Phone Number)(Owner/Operator of Septage Management Firm)
of L_e_e s_e~p_t_i_c__&__L_a_n__d ~N~C~S~#__0_1_4_4_1
(Septage Management Firm Name and NCSnumber)
to dispose of:domestic septage x -'portable toilet waste x -'
grease septage (grease trap pumpings)commercial/industrial septage -'from
Elizabeth City,Pasquotank County
(County or other Geographic Area)
at the above named wastewater treatment facility.Septage shall be discharged at:
Elizabeth City WWTP,450 Knobbs Creek Drive,Elizabeth City,NC 27909
(Location)
betweenthehoursof 7_:_0_0_AM__-_7_:_0_0_P_M -------------
Reintroducing partially treated liquid into a grease trap is acceptable __Yes __X_No
December 31,2019
(Usually December 31,Year)
Date 26/t1AG-/9
srb0r:d.and affrmed belor;m)ethis -,.--_--'a~lp_'__day 01 fnlgtA-,20 Iq
~:.J11-g-My Commission expires:1\-2-2020
(Not ryPublic)-:<,-",-'"(OFFICIAf"SEA~--or--...
Note:Falsification of this document by the septage management firm shall lead to permit revo~i~_•
S:/Solid_Waste/CLA/SEPTAGE/FORMS/2018 Firm Application/WWTP Authorization Form 2018 "••••~=.......-