NCS00236_2023Permit_Initial

2023
Permit and Registration
Leathermans Septic Tank Ser. Inc.
is hereby issued a Septage Management Firm Permit,
ot�N STATE,,
Permit Number NCS-XXXX
o and registered as aD E
12 -�� Septage Management Firm Department of Environmental Quality
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, Hickory, 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.
Wrn Perry Sugg
Digitally signed by Wm Perry
Sugg
Date: 2023.02.02 12:26:22-05'00'
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, NC 27699-1646
(1.) Firm name: (The "Firm name" must be ex� as it is shown on your vehicle(s)).
Street address of office: A G
City:_ Ljt� OLI to n
Mailing address (if different):
City:
E-Mail: oar �f3,�6�1•r��^
County:_
State:
Zip
Septage Management Firm permit number: NCS #
(2.) Firm owner's name: - I erm.; n
Mailing address (if different):
City: State: Zip
Phone: TD 5�d 2 ,�9� Fax: 70 �e z
(3.) Firm operator's name: A19 r V Cv e42,j&/,Aikivbperator's title:
Mailing address (if different):
City:
Phone:
State: Zip:
Fax:
(4.) Type(s) of septage pumped: Write in the number of gallons oumoed in last 12 months (Example: Domestic: 50,000).
(5.) N.C. Counties of Operation:
Treatment Plant
(List each county you are authorized to do business in)
(6.) Total Number of Pumper Vehicles Operated: f
Number used for: Domestic Septage:Grease (restaurant):
Other: Portable Toilet Waste:
Vehicle Information: (use additional paper if needed)
mercial
License Tag #
Vehicle Identification #
Tank Capacity
1
C 6 d
2 S-0 D �, 4
2
✓
3
4
5
APPLICATION CONTINUED ON PAGE 2
PAGE 1

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
(CONTINUED FROM PAGE 1)
(7.) Do you plan to operate pumper vehicles? (check one) ( pl'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? (/es ( ) no Initial Date 2 Z 2-
(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#:. 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 Management Firm Operator Training Completed:
Date: 2 - 2 Z Location: / // C-/<,, � Hours:
Training Sponsored or Provided by: IbIC 5' %'4 _
(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
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 ( nature of company official required) Date
Irg '*� y z e-0 A e/7m4 _ /Ple S c/e.
Print Nam6 Title
Other Comments:
Rev. 04-26-2021
PAGE 2

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.
Shawn Pennell. City of Hickory
(Plant Operator and Name of Plant)
4014 River Rd, Hickory, NC 28602
828-323-7427
(Phone Number)
(Address)
do hereby authorize Gary Leatherman
(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
(Location)
between the hours of 7:00am and 7:00pm
Reintroducing partially treated liquid into a grease trap is acceptable Yes X No
This authorization shall be valid until December 31.2023
(Usually December31, Year)
Signed Date //I] C 2,40 r ZA--
(Facility Opera r) V
Swom to and 3su dbed before me this day of 20
Ak My Commission expires A 1-co
Notary Public)
11111111fI�/
(OFFI % VBf%, fi,�
1• •y ��I
Note: Falsification of this document by the septage management firm shall lead to permit revocation. Y ?� V
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