NCS00394_2023Permit_Initial

2023
Permit and Registration
Cooper Septic Tank Service, LLC
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-00394
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. City of Lumberton WWTP, Lumberton, NC
2. Septage Land Application Site, SLAS-83-04, SLAS-78-20
3. Septage Detention or Treatment Facility, SDTF-83-04
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.
Wail Digitally signed
by Wm Perry
Perry Sugg
Date: 2023.02.02
Sugg 13:10:08-05'00'
Perry Sugg, Environmental Compliance 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*
Cooper Septic Tank Service, LLC
The "Firm name" must be exactly as it is shown on your vehicle(s).
Septage Management Firm permit number (NCS #)
00394
Please enter the complete NCS #, including the 5 end digits (NCS-XXXXX)
Street address of office*
Street Address
387 S Hilltop Rd
Address Line 2
City
State / Province / Region
Red Springs
North Carolina
Postal / Zip Code
Country
28377
United States
County*
Hoke
Mailing address same as street address of office?*
Yes • No
Mailing Address*
Street Address
PO Box 645
Address Line 2
City
State / Province / Region
Wagram
North Carolina
Postal / Zip Code
Country
28396
United States
Phone*
Fax
9103692713
Email*
[e-mail]
Owner Info
Firm owner's name*
Randall Cooper and Emily Cooper
Mailing address same as street address of office?*
Yes 0 No

Mailing Address*
Street Address
PO Box 645
Address Line 2
City
WAGRAM
Postal / Zip Code
28396
State / Province / Region
North Carolina
Country
United States
Phone* Fax
9103692713 9103692295
Operator Info
Firm operator's name* Firm operator's title
Emily Cooper part owner
Mailing address same as street address of office?*
Yes • No
Mailing address*
Street Address
PO Box 645
Address Line 2
City
State / Province / Region
Wagram
North Carolina
Postal / Zip Code
Country
28396
United States
Phone* Fax
9103692713 9103692295
Type and amount of septage pumped in the last 12 months
Amount in gallons*
Domestic 315,000
Portable Toilet Waste 0
Grease (Restaurant) 102,000
Treatment Plant 0
Industrial/Commercial 0
North Carolina counties of operation
List each county you plan to do business in: *
Hoke, Scotland, Richmond, Robeson, Cumberland, Moore
Vehicle Info
Do you plan to operate pumper vehicles?*
0 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
41 rri✓elf- +-off
Date*
12/30/2022
Title*
Part owner
Choose how to add vehicle descriptions*
• Add vehicles individually Upload List
Pumper Vehicles
Usage*
License Tag #*
Vehicle Identification #*
Tank Capacity*
Domestic Septage
YA151104
1HSHJAZNlPH514950
2,500
Grease (restaurant)
YA151104
1HSHJAZNlPH514950
2,500
Domestic Septage
YA126977
1HSHJAZNONH460859
2,300
Grease (restaurant)
YA126977
1HSHJAZNONH460859
2,300
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*
City of Lumberton 12/31/2023 0624 2212301... 56.03KB
Septage Land Application Sites (SLAS) *
• Yes No
If you are not the permit holder for the septage land application site, you must have a signed land application authorization form for each site.
Permit Verification
O I certify that I AM the permit holder for this SLAS.
If unchecked, please attach a signed land application authorization form for each site.

SLAS #*
Expiration Date*
SLAS-8304 7/30/2023
SLAS-7820 7/30/2023
Septage Detention or Treatment Facility (SDTF) *
• Yes No
Permit Verification
✓ I certify that I AM the permit holder for this SDTF.
If unchecked, please attach a signed detention/treatment authorization form for each site.
If you are not the permit holder for the septage detention/treatment facility, you must have a signed detention/treatment authorization form for
each site.
SDTF #*
Expiration Date*
SDTF-8304 7/30/2023
Other disposal method*
Yes • No
Septage Management Firm Operator Training Completed
Date* Hours*
4/12/2022 6
Location*
Shallotte, NC
Training Sponsored or Provided by*
NC Septic Tank Association
Septage Land Application Site Operator Training Completed
Date Hours
4/12/2022 6
Location
Shallotte, NC
Training Sponsored or Provided by
NC Septic Tank Association
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
elf &cam
Date
12/30/2022
10:36:53 AM
Print Name* Title*
Emily Michelle Cooper part 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, Henry Harper; ORC # 1008147 City of Lumberton Waste Treatment Plant
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
700 Lafayette Street, Lumberton, NC 28358 Contact: Tammy Smith 910-671-3858
(Address) (Contact / Phone Number)
do hereby authorize Randy and Emily Cooper [phone]
(Owner/Operator of Septage Management Firm)
of Cooper Septic Tank Service PO BOX 645 Wagram NC 28396 NCS # 00394
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage Yes , portable toilet waste Yes
grease septage (grease trap pumpings) _N commercial/industrial septage Yes from
Robeson and Surround
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
The Influent Basin at 700 Lafayette Street Lumberton, NC 28358
(Location)
between the hours of 7 am to 4 pm Monday — Friday. No weekends or Holidays
Reintroducing partially treated liquid into a grease trap is acceptable Yes X No
This authorization shall be valid until December 3111 2023
(Usually December 31, Year)
Signed Date
(facility Operator)
Subscribed and affirmed before me this day of / 10yte ,w 20
My Commission expires: /0�/g 14D as—
(Not lic)
(OFFICIAL SEA Q TAMMY L SMITH
NOTARY PUBLIC
BLADEN COUNTY, NC
Note: Falsification of this document by the septage management firm shall lead to permit revocation. My Commission Expires 10-19-2025
S:/Solid_Waste/CLA/SEPTAGE/FORMS/2014 Firm Application/WWTP Authorization Form 2014

NC SEPTAGE MANAGEMENT FIRM
Recertification of Pumper Vehicle(s)
Septage Firm Permit #: NCS- W 30M
Number of Pumper Vehicles: I
Q
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."
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Signature (Si I
ature of company o icial required)
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Print Name
Date
1gf
Title
S:lSolid_WastelclalseptagelformslPumper Vehicles Cetification.doc