NCS00457_2022Permit_Initial

2022
Permit and Registration
Jeff Lawson Septic Tank & Pumping Service
is hereby issued a Septage Management Firm Permit,
tszArr of
Permit Number NCS-00457
and registered as a
CIA)
o
=NORTH CAROLINA
Septage Management Firm Department of Envlr mmentalQuality
�
E#f 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, Tide 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 3. Septage Detention or Treatment Facility, SDTF-85-06
2. Town of Walnut Cove 4. Septage Land Application Site, SLAS-85-06
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. Digitally signed by
_W_
_6e� Wm Perry Sugg
Date: 2022.10.02
20:26:52-04'00'
Perry Sugg, Environmental Compliance Branch Head

LAB i: � 2 -Io'-DCr NCt:W- 0,G4-6'�'7
APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
DIVISION OF WASTE MANAGEMENT - SOLID WASTE SECTION —1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646
RECEIVED
(1.) Firm name: (The "Finn name" must be exactly as it is shown on your vehicle(s)).
_�' �� /.��..1 oon I ��t�t(� Un �t r7t . v` I NOV 2 9 2021
Street address of office: � l N NIL.
City: D 1 b u t"c.1 State:
Mailing address (if different):
Zip: DEO-FAYETTEVILLE RENAL OFFICE
City: State: Zip:
Phone: ` ;(�.� ) '_] " % _ Fax:
E-Mail: JOF Iau-) fl�-;erj t; C4oj) k 1r, ('i n- ;ird • ( `
County:�`�c'C Septage Management Firm permit number. NCS #_i]U4-6q
(2.) Firm owner's name:
Mailing address (if different):
State: Zip:
Phone: 5� - C - L W & Fax:
(3.) Firm operator's name: J'�'F tr LA/' J- } Firm operator's tine: D W- 06f—
Mailing address (if different):
City: _ State: Zip:
Phone: Fax:
(4.) Type(s) of septage pumped: Write in the number of -gallons pumped in 2016 (Example: Domestic: 50,000).
City:
Domestic I Portable Toilet Waste Grease Restaurant
Treatment Plant
Industrial/Commerdal
i % CC
(5.) N.Cl unti'Ires of 0peration: :DfL, K e- ��'���L 'j'fl t •�� ! 1 r It �
(List each county you do business in)
(6.) Total Number of Pumper Vehicles Operated:
Number used for. Domestic Septage: Grease (restaurant): _
Other. Portable Toilet Waste:
Vehicle Information: (use additional paper if needed)
License Tag #
Vehicle Identification #
TankCapacityj
fAZ 0 1,,1 -'
IG1W7I W F bQ [ 14 5
r� eJ�0
2
4r-7' `t
Z� I .
gi i
❑ i
3
4
_
5
APPLICATION CONTINUED ON PAGE 2
PAGE 1
Ofl

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
(CONTINUED FROM PAGE 1)
(7.) Do you plan to operate pumper vehicles? (check one) (.yes ( ) 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 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 are significant penalties for false certification including the
possibility of fine and imprisonment."
Do you attest to the statement above? (V) yes ( ) no Initial \ 7 Date , i �' �'-C
(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 .0834(c)(14) of the Septage Management Rules.
b) Septage Land Application Site (SLAS) Permit Numbers: (use additional sheets if needed)
SLAS#: r.. 70 Expiration Date: 161 - 3I- SLAS#. Expiration Date:
c) Septage Det ntion or Treatment Facility (SDTF) Permit Numbers: (use additional sheets if needed)
SDTF l� Expiration Date: 5t i-:�A SDTF#. Expiration Date:
(9.) Septage Management Firm Operator Training Completed:
Date: J D - f q - , _ Location: 50M f3 r-M,1 U W) RC(* Hours:
)rot17.41 '
Training Sponsored or Provided by: I(J�,J%I GiUn
(10.) Septage Land Application Site Operator Training Completed:
Date: i D -1q -A 1 Location: 5$ 3413ur-NI1'1 C ktb tom. Hours:
r ]� r�r� 7 � u {✓L � p
Training Sponsored or Provided by: `oeo o'? i (af* 6/)D,l aho n
(11.) Registration type requested: CHECK ONE
Registered Portable Sanitation Firm:�
Registered Septage Management Firm: o/
Registered Portable Sanitation and Septage Management Firm:
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.
r
Signati�' (.: a of companyoffrcial required)
d2W L-0.U_)6or)
Print Name
Other Comments:
Date
b-A,"V-1�
Title
PAGE 2
Rev. 04-26-2021

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, _Matthew Lavigne- WW#997822-Archie ElledFe Wastewater Facility
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
2801 Griffith Rd. Winston-Salem, NC 27103
(Address)
336-765-0130 do hereby authorize Jeff Lawson
(Phone Number) (Owner/Operator of Septage Management Firm)
of Jeff Lawson Septic Tank & Pum piny, Service _ NCS # 00457
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage X
grease septage (grease trap pumpings)
, portable toilet waste
commercial/industrial Septage _ from
Winston-Salem/Forsyth County and Adiacent Counties
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
Archie ElledSe Wastewater Facility
(Location)
between the hours of 6:00 am until 6:00 Pm Monday Through Saturday_
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 Date %d ` 27- a 1
(Faci ' Operator)
Subscribed and affirmed before me this :r _ day of L .20 2 )
My Commission expires: __ OZ2
(Notary Public)
REBEP;AAAG )REN
Notary -Public-North .Carolina - �-
CCLINTY OF FORSYTH
My Commission Expires: 30
Note: Falsification of this document by the septage management firm shall lead to permit revocation.
S:/Solid Waste/CLA/SEPTAGE/FORMS/2018 Firm Application/WWTP Authorization Form 2018

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, 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.
M
0
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
D& ai Wa(nw- G'-t 9-205A
(Address) r
do hereby authorize Ion
(/P�hhone /un�N1u�m'beer)) f /(Owner/Operator of Septage Management Firm)
of Jeri" b 6on � 4� � ���i a- p�Lrnpll '4 �)erI ct-- NCS # . 14(5(7
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage _, portable toilet waste
grease septage (grease trap pumpings) commercial/industrial septage _ from
114
ke'5
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
Lacon
(Location)
between the hours of V'30 — Cabo
Reintroducing partially treated liquid into a grease trap is acceptable ✓ Yes No
This authorization shall be valid until31,
�1
(Usually December 31, Year)
i
Signed :y
g � Date-1a'yi2b2,(
(Facility Operator)
S scribed and affirmed before me this day ofk ilC 20 � 1
huli e My Commission expires: mi II1l91 �
(Notary Public)Ch;
O
7
�' ((al6fil�jA�uSH�L)m
_ Stokes
County _
Note: Falsification of this document by the septage management firm shall lead to
5:/Solid_Waste/CLA/SEPTAGE/FORMS/2016 Firm Application/WWTP Authorization Form 2017

FIRM NAME: Jeff Lawson Septic Tank & Pumping Service
PERMIT #: NCS-00457
AMOUNT: $800
PAID BY: Check
DATE:
Adam Ulishney