NCS00051_2023Permit_Initial

2023
Permit and Registration
Norman's Septic Tank Service
is hereby issued a Septage Management Firm Permit,
ZNti STATE
Permit Number NCS-00051
o and registered as a
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-�� Septage Management Firm�� �� w� ��nffii�utr
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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. Lexington Regional WWTP, Lexington, 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.
(,� 1)4 �Y 12/01 /2022
Perry Sugg, Eentairifompliance Branch Head

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
DIVISION OF WASTE MANAGEMENT - SOLH) WASTE SECTION -1646 M SERVICE CENTER, RALEIGH, NC 276994 46
(1.) Firm name- (l "Rrm name"' must be era as It is shown on your vehicte('s)).
IYO ►^ maji-'-s k--Sev vp cf-,,
Street address of office: °I U 5 oww4
City: LC1Nn Stater Zip:
Mailing mess (if dilferaent): -
city: slate: Zip.
Pfhone:33(o- 18 1-I43_i Fax: —E-Mail:n har• n 0 w i'n r Ji-eft m. n e-t OA a r•Afa;
y Dty! Soo
(2:) Firm owners name:.
Mailing address (if different):
(3.) Firm operators
Mailing address (if dgerent):
Management Firm permit number: NCS
Rct4 / &y'1Yh&N
NF
n v, I a6:x's tit , Ca -0W t1-e Ns
City: state: Zr):
phone. 3, j (v - I tq -5 q 2 S Fax:
(4.) Type(s) of septage pumped: 411 & in the number of gallons igumned in bast 12manIhS (Example: Domestic: 50,M).
I Domestic I Portable Toilet Waste I Grease (Restaurant) I Treatment Plant I fIndustriaYCommerdal I
( ..Miescxf Qperalzon: - �V I ds6
List each coudY you are aurtirortzedl to do business In)
(S.) Total Dumber of Pumper V'ehides Operated: I
Number used fbr: Dornestit Septagve: I Grease (restauranQ:
Sher: Portable Toilet Waste;,
Vehfde Information: (use additional paper if rreede€i)
License Tag #
Vehicle Ident.ilication €i:
Tank Capacity
1 4
WEltwv
b
2
3
4
5
APPLICATION CONTINUED ON PAGE 2
PAGE 1

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
(CONTINUED FROM PAGE I
(7.) Igo you plan to operate pumper veN des? (check one) yes( ) no.
It you checked yes above, you must attest to the following statement before a permit may be issued.
"II crrrtify, 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 reed by 15A NCAC 130 .M5(a) and vehicle lettering
as required by€15A NCAC .0835(b). Furthermore, I also certify that a lag is maintained of each septage pumping event as
required by 15A NCAC 13S .0835(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? (1,/) yes ( ) no Initial_, .V Efatejill l L � AO k 2L
�.. Septage Disposal Method: (check one)
a) leved wastewater treatment plant ✓) yes no. If yes; submit Wastewater Treatment XMorization for each
plant, as indicated in Subparagraph .f834(c)(14) of theSeptage Management Rules.
b) Septage Land Application Site (SLAS) Permit Numbers: (use additional shams if needed)
SLASM Expiation Date: SLAS#: Expiration Date.
c) Septage Detention or Treatment Facility (SDTF) Permit Numbers. (use additional sheets ifneeded)
SDTF#: Expiration Date: SDTF#: Expiration Date.
(9.,) Selage Manager nt Fi m Operator Training Completed:
Date: ©$ 13 001-a- Locabon: hNproo VI
,-AV„ Hours: �-
Training Sponsored or Provided by: J Lnahgy, (S-j��pjj in
Septage Land ApplicAm Site Operator Trading Completed:
Date: Location:
Training Sponsored or Provided by:
(11.) Registration We requested: CHECK ONE
Registered Portable Sanitation Firm..:
Registered Septage Management Firm: —V—
Registered Portable Sanitation and Septage Management Farm:
Certification Statement
I coft that ft Wormafirrn and rep entations in this applik atlon for a permit are true, comlpllet% and accurate to thebeg
-
of my knowledge and belief I am aware drat a permit may be suspended or revoked upon a finding that Its issuance was
based upon incorrect or inadequate Information that materially aftcled the decision to issue the permit and that there are
criminal penalties far knowingly making a false statement: representation, or ce> ation.
S�g" az
_ (Sgrr`anArnre of eornpanyafti're""
Print Ndne
Other Comments:
l I 14
Date
Title
Rev. 04-2&2021

NC SEPTAGE MANAGEMENT FIRM
Recertification of �'umper Vehicle(s)
Septage Firm Permit #:_.
Number of Pumper Vehicles:
NCS- 000 5 1
CERTIFICATION:
"I certify, under penalty of law, that the pumper vehicle or vehicles listed in the
submitted permit application meet the requirements for safe and sanitary
transportation of septage as required by15A NCAC 13B .0844 (a) and vehicle
lettering as required by 15A NCAC 13B .0844 (b). 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 are significant penalties for false certification including
the possibility of fine and imprisonment."
Sign (ftnature of company official required)
wo�tv- \/\/,
Print -Nam
,1114
Date
Co Kf- r-
Title
S:Molid WastelcialseptagelformslPumper Vehicles Cetification.doc

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. 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.
I, V1T►'R� "11 t Liz _}C -OfUL Q `►a. <. i
(Plant Operator in Responsible Charge (ORC), O License Numb , Name of Plant)
¢. %+
(Address)
911300
%# W 3
- t N C—
A+k<0-
C3� .ZVQ 6�1�do hereby authorize OOJ a - NO �2-1 0AA_
(Phone Number) (0 /Operator of Septage anagement Firm)
00051
ptage Management Firm Name and NCS number)
to dispose of: domestic septage V portable toilet waste '✓ ,
grease septage (grease trap pumpings) commercial/industrial septage from
Ci v-1A
(County or o0eJ Geographic Ar'd)
at the above named wastewater treatment facility. Septage shall be discharged at:
C—
between the hours of
Reintroducing partially treated liquid into a grease trap is acceptable Yes NJ' No
This authorization shall be valid until �'� j 2D 3
(Usually December 31, Year)
Signed Date
(Facility Operator)
Subscribed and affirmed before me this �L _ day of L 20
'�ZVAI . I ILUrl(w
(Notary Public)
My Commission expires: V -as -- 04Gk7
Jamie Free an
Notary Pu��lclai. s AI.)
Davidson Coun , NC
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

1W North Carolina Department of Environmental Quality
Division of Waste Management INVOICE
NOHiH CAROLINA
Solid Waste Section
Division of Waste Management
Solid Waste Section
1646 Mail Service Center
Raleigh, NC 27699-1646
Phone/Fax: [phone]
Email: [e-mail]
Septage - Annual:
Norman's Septic Tank Service (NCS-00051)
5999 West US Hwy 64
Lexington, NC 27295
Number of Trucks: 1
To: Ray Norman Roger Norman
Norman's Septic Tank Service
S999 West US Hwy 64
Lexington, NC 27295
!� x�
".
F.
CK. NO. 3-77%
DATE ! I-71 -
43 CD,Ob
Date Due:
Date: 09/27/2022
Invoice #: NCS-00051-2023
$ 550.00
LATE FEES:. In accordance with NC General Statutes GS 130A-291.1(e2), a late fee will be applied to any annual permit fees not submitted by January 1, 2023.
Payment Optiom:
E-check Available online at https://deq.nc-gov/swpa i
Requires bank account and routing information. You will need to use the zip code in the description box and the invoice number
shown on this invoice to access your account. If a zip code is not listed, use the code: 99999 along with the invoice number.
Credit Card Available online at ttps://deq.nc.aov/swpav
Accepts MasterCard, Visa, and Discover cards. You will need to use the zip code in the description box and the invoice number shown
on this invoice to access your account. If a zip code is not listed, use the code: 99999 along with the invoice number.
[*Convenience Fee of 2.65% added to amount invoiced.]
Paper check Make checks payable to N.C- Division of Waste Management, Solid Waste Section, include Permit Number and invoice number on
check. If you are paying by electronic transfer, include the invoice number with your electronic transfer. Please return a copy of this
invoice with your payment
[G.S. 25-3-506: A $25.00 processing fee will be charged on all returned chedcsj
Ex-:lanation of Invoice Amount is Based on Firm's Current Permit Status:
Pursuant to North Carolina General Statute 130A-291.1 you are required to pay fee(s) based on your solid waste management
activities. The fee(s) shall be used to support the septage management program.
For quesb -ns regarding:
Billing
Regulations or Technical Assistance
Jared Wilson [phone]
Chester Cobb [phone]
Jeffrey Bullard [phone]
More information available on the web:
North Carolina Department of Environmental Quality (DEQ) - �ittr.s:., deo.nc.3ov
North Carolina Solid Waste Program - a� L'divisions:wage-management/solid-waste-section
North Carolina Septage Management Program - .T e1.n :�rro.',La V divigons/waste-manaaement/solid-waste-section/special-was es-and-altern tive-
handlir