NCS01068_2022Permit_Initial

2022
Permit and Registration
Piedmont Disposal

is hereby issued a Septage Management Firm Permit,
Permit Number NCS-01068
and registered as a Septage Management Firm
(PUMPER)
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. Archie Elledge WWTP, Winston-Salem 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, 2022.

__________________________________________________ Perry Sugg, 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 oce*
County*
Mailing address same as street address of oce?*
Phone*Fax
Email*
Firm owner's name*
Mailing address same as street address of oce?*
Phone*Fax
Firm operator's name*Firm operator's title
Mailing address same as street address of oce?*
Firm Info
PIEDMONT DISPOSAL
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-01068
Enter the five digits following the NCS #
City
WINSTON SALEM
State / Province / Region
NC
Postal / Zip Code
27106
Country
US
Street Address
4420 PROVIDENCE LN
Address Line 2
Forsyth
Yes No
336-777-8805
[e-mail]
Owner Info
JOSEPH M LONG
Yes No
336-777-8805
Operator Info
TIM GARDNER CFO
Yes No
Phone*Fax
Amount in gallons*
Domestic
Portable Toilet Waste
Grease (Restaurant)
Treatment Plant
Industrial/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 .0835(a) and vehicle lettering as required by 15A NCAC .0835(b).
Furthermore, I also certify that a log is maintained of each septage pumping event as required by 15A NCAC 13B .0836(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*
336-777-8805
Type and amount of septage pumped in the last 12 months
0
205,200
0
0
0
North Carolina counties of operation
FORSYTH, GUILFORD, DAVIE, DAVIDSON, STOKES, YADKIN, ROWAN, SURRY, IREDELL
Vehicle Info
Yes No
11/10/2021
CFO
Add vehicles individually Upload List
Portable Toilet Waste HP1681 5PVNV8JT3D4S52967 1,000
Portable Toilet Waste KX8163 1FVACWD22NHNA9395 1,000
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Approved wastewater treatment plant*
If yes, list the facilities below and upload or submit by mail a copy of Wastewater Treatment Authorization for each plant as indicated in
subparagraph .0833(c)(14) of the Septage Management Rules.
Mail forms to:
NC DEQ
Division of Waste Management - Solid Waste Section
1646 Mail Service Center
Raleigh, NC 27699-1646
Wasterwater Treatment Facility Name*Expiration Date*Authorization
Septage Land Application Sites (SLAS)*
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
Yes No
ARCHIE ELLEDGE WASTEWATER FACILITY 12/31/2022 BRN3C2AF4B91…202.11…
Yes No
Yes No
Yes No
Septage Management Firm Operator Training Completed
6/9/2021 4
THE VILLAGE INN 6205 RAMADA DR CLEMMONS, NC 27012
NC Septic Tank Association
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*
Certication 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.
10/25/2021
10:00:00 AM
TIM GARDNER CFO
PAID
FIRM NAME: Piedmont Disposal
PERMIT #: NCS-01068
AMOUNT: $800
PAID BY: E-Check
DATE: 11/15/2021

Adam Ulishney