NCS00236_2022Permit_Initial

2022
Permit and Registration
Leathermans Septic Tank Ser. Inc.
is hereby issued a Septage Management Firm Permit,
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Permit Number NCS-00236
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o and registered as a
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` a= Septage Management Firm Department ofEnvironmental Quality
44 QIIAM
NORTH CAROLINA (PUMPER)
Environmental Quality
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. City of Hickory WWTP
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.
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Digitally signed by Wm
Perry Sugg
Date: 2022.10.02
20:22:34-04'00'
Perry Sugg, Environmental Compliance Branch Head

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
DIVISION OF WASTE MANAGEMENT - SOLID WASTE SECTION -1646 MAIL SERVICE CENTER, RALEIGH, I&CR99-11646
VED
0.) Firm name: (The "Firm name" must be exactly as it its shown on your vehkle(s)). SEp 2.7 2021
Street address of office: �I 2__. Sol
i - ��-SSTF SECT►ON
City: Stater Zip: J101 2-
Mailing address (if different):
City:
Phone:
State: Zip
F
E-Mail: Q ryJ 3 ,14 i1A_74m u• /' Goo -
County: rz _. Septage Management Firm permit number: NCS # _P_(2.Z T4
(2.) Firm owner's name:
Mailing address (if different):
City: State: Zip
Phone: 17&y �z C 2- 215 �t Fax: z,4- !Z bl .2-. 2,
(3.) Firm operator's name: < w Firm operator's title:
Mailing address (if different):
City:
State: Zip:
Fax:
(4.) Type(s) of septage pumped: Write in the number of gallons oumned in last 12 months (Example: Domestic: 50,000).
Domestic
-Z 0 o, 00 0
(5.) N.
Portable Toilet Waste Grease (Restaurant) Treatment Plant Industrial/Commercial
of Qgeration:
(6.) Total Number of Pumper Vehicles Operated:
Number used for: Domestic Septage:
Other:
Vehicle Information: (use additional paper if needed)
you are
Grease (restaurant):
Portable Toilet Waste:
License Tag #
Vehicle Identification #
Tank Capacity
I
YULY 14116fi
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ISO 0
2
3
4
5
APPLICATION CONTINUED ON PAGE 2
PAGE

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
(CONTINUED ROM PAGE 1)
(7.) Do you plan to operate pumper vehicles? (check one) ( %s ( ) no.
If you checked yes above, you must attest to the following statement before a permit may be issued.
"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 NCAC13B .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 are significant penalties for false certification including the
possibility of fine and imprisonment."
Do you attest to the statement above? (Vf yes ( ) no Initial Cr H 1- Date ? - /i
(8.) Septage Disposal Method: (check one)
a) Approved wastewater treatment plant: ( ) yes ( ) no. If yes, submit Wastewater Treatment Authorization for each
plant, as indicated in Subparagraph .0833(c)(14) of theSeptage Management Rules.
b) Septage Land Application Site (SLAS) Permit Numbers: (use additional sheets if needed)
SLAS#: Expiration Date: _SLAS#: Expiration Date:_____
c) Septage Detention or Treatment Facility (SDTF) Permit Numbers: (use additional sheets if needed)
SDTF#: Expiration Date: SDTF#: Expiration Date:
(9.) Septage Managemen Firm Operator Training Completed: i
Dater Location: C Hours:
Training Sponsored or Provided by:
NC- 5 TI-1
(10.) Septage Land Application Site Operator Training Completed:
Date: Location: Hours:
Training Sponsored or Provided by:
(11.) Registration type requested: CHECK ONE
Registered Portable Sanitation Firm:
Registered Septage Management Firm:
Registered Portable Sanitation and Septage Management Firm:
Certification Statement
-1 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.
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Signature ( ignature of companyofficial required)
C—,, ^� er
Print Name
Other Comments:
Date
Title
PAGE 2
Rev.10-27-2020

AUTHORIZATION TO DISCHARGE SEPTAGE TO A WASTEWATER
TREATMENT FACILITY
North Carolina Department of Environment and Natural Resources
Division of Waste Management - Solid Waste Section
1646 Mail Service Center, Raleigh, NC 27699-1646
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.
I, Shawn Pennell. City of Hickory
4014 River Rd. Hickory,NC 28602 (Plant Operator and Name of Plant)
(Address)
828-323-7427 do hereby authorize Gary Leatherman
(Phone Number) (Owner/Operator of Septage Management Firm)
of Leatherman's Septic Tank Service. Inc. NCS # 00236
(Septage Management Firm Name and NCS number)
to dispose of. domestic septage X , portable toilet waste
grease Septage (grease trap pumpings)-------- commercial/industrial septage--------- , from
Catawba. Lincoln. and Burke
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
Old Brookford Plant
between the hours of _ 7:0Oam and 7:00pm (Location)
Reintroducing partially treated liquid into a grease trap is acceptable Yes X No
This authorization shall be valid until December 31.2022
(Usually December 31, Year)
Signed 4- - � � �
Date
city Operator)
Sworn to and subscribed before me this
( tary Pub' )
day of 20 2-1_
My Commission expires:
Note: Falsification of this document by the septage management firm shall lead to permit revocation.
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