NCS00023_2023Permit_Initial

2023
Permit and Registration
Grimes Septic Tank Pumping
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-00023
o and registered as a
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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. 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, 2023.
12/01 /2022
Perry Sugg, En onmental tompliance Branch Head

For questions regarding this form or the online application process, please contact Jeffrey Bullard (919-707-8285) or Chester Cobb (919-707-
8283).
Firm Info
Firm name*
Grimes septic tank pumping
The "Firm name" must be exactly as it is shown on your vehicle(s).
Septage Management Firm permit number (NCS #)
NCS-00023
Enter the five digits following the NCS #
Street address of office*
Street Address
1536 Richmond hill church rd
Address Line 2
City
State / Province / Region
Boonville
INC
Postal / Zip Code
Country
27011
United States
County*
Yadkin
Mailing address same as street address of office?*
• Yes No
Phone* Fax
3364699710
Email*
[e-mail]
Owner Info
Firm owner's name*
Jody Grimes
Mailing address same as street address of office?*
• Yes No
Phone* Fax
3364699710
Operator Info
Firm operator's name* Firm operator's title
Jody Grimes Owner
Mailing address same as street address of office?*
0 Yes No

Phone* Fax
3364699710
Type and amount of septage pumped in the last 12 months
Amount in gallons*
Domestic 600,000
Portable Toilet Waste 0
Grease (Restaurant) 0
Treatment Plant 0
Industrial/Commercial 0
North Carolina counties of operation
List each county you plan to do business in: *
Yadkin Forsyth Davie Davidson Surry Stokes
7yehicle Info
Do you plan to operate pumper vehicles?*
• Yes No
"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*
10/30/2022
Title*
Owner
Choose how to add vehicle descriptions*
• Add vehicles individually Upload List
Pumper Vehicles
Usage*
License Tag #* Vehicle Identification #* Tank Capacity*
Domestic Septage
YA1O4O13 1FVACWDC46HW25888 2,500
Domestic Septage
YA147646 2NP3LJOX9LM668404 4,000
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.

Approved wastewater treatment plant*
• Yes No
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
Archie Elledge 12/31/2023
Septage Land Application Sites (SLAS)
Yes • No
Septage Detention or Treatment Facility (SDTF)
Yes • No
Other disposal method*
Yes � No
Septage Management Firm Operator Training Completed
Date* Hours*
3/17/2022 4
Location*
Clemmons NC
Training Sponsored or Provided by*
NC Septic Tank Association
Septage Land Application Site Operator Training Completed
Date Hours
0
Location
Training Sponsored or Provided by
Registration Type
Select one*
Registered Portable Sanitation Firm
• Registered Septage Management Firm
Registered Portable Sanitation and Septage Management Firm
Comments and Notes
Comments or notes

Certif cation 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.
Signature
Date
10/30/2022
10:35:04 AM
Print Name* Title*
Jody Grimes Owner

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 Laviene- WW#997822-Archie Ellede Wastewater Facilitv
(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 Jody Grimes
(Phone Number) (Owner/Operator of Septage Management Firm)
of Grimes Se[]tic Tank NCS # 0023
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage X portable toilet waste _ _X
grease septage (grease trap pumpings) _ NO commercial/industrial Septage , from
Winston-Salem Forsyth County and Adjacent Counties
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
Archie Elled a Wastewater Facilitv
(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. 2023
(Usually December 31, Year)
Signed _ Date 1,O—. AC? a -
(Fa ' y Operator)
Subscribed and affirmed before me this. 3 f� _ day of OC.+o L,, , 20 3-2'
1� -s�!� My Commission expires: 31 J-312D ate_
(Notary Public) MARY G. BROWN
RECEIVED 1(9
Notary Public. North Carolina
Forsyth County (OFFICIAL SEAL)
My C mis ion Expires
NOV 0 2 202Z
Note: Falsification of this document by the septage management firm shall lead to permit revocation.
$OLID/Vi/AS1jl6tN07"NGE/F0RM5/2018 Firm Application/WWTP Authorization Form 2018