NCS00457_2023Permit_Initial

2023
Permit and Registration
Jeff Lawson Septic Tank & Pumping Service
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-00457
o and registered as a
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NORTH
EQ
4%L 12. 9*
-�� Septage Management Firm�� �� w� �nffii�utr
E� M
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. Septage Land Application Site, SLAS-85-06
2. Septage Detention or Treatment Facility, SDTF-85-06
3. Archie Elledge WWTP, Winston-Salem, NC
4. Town of Walnut Cove WWTP, Walnut Cove, 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. V V \ A M
Digitally signed
by Wm Perry
Perry
Sugg
Sugg
Date: 2023.02.02
13:12:05-05'00'
Perry Sugg, Environmental Compliance Branch Head

-SEAS #7
NCB 4*-0D4!5'7
APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
DIVISION OF WASTE MANAGEMENT - SOLID WASTE SECTION -1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646
(1.) Firm name:
Street address offi f ce: UI L4
City: )
Mailing address (if different):
City: State: Zip
Phone: 33 - I , 61 L� rr�� '74 Fax:
E-Mail: W e I a, n � n):T C� K A m-YT 7 (' L,
County: `0 ' `� r 11Septage Management Firm permit number: NCS # M
(2.) Firm owner's name: LoijJon _
Mailing address (if different):
City:
(3.) Firm operator's
Mailing address (if different):
City: 7 State: Zip:
Phone: I /Fax:
operator's title: O W n 61-
LA
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(4.) Type(s) of septage pumped: Write in the number of gallons oumoed in last 12 months (Example: Domestic: 50,000).
Portable Toilet Waste I Grease (Restaurant) I Treatment Plant
(5.) N.C. Counties of Option:`
you are authorized to do business
(6.) Total Number of Pumper Vehicles Operated: Q
Number used for Domestic Septage: Grease (restaurant):
Other. Portable Toilet Waste:
Vehicle Information: (use additional paper if needed)
License Tag # Vehicle Identification #
Tank Capacity
-- D N .J (D'141pr
t! on-)
z
l4-`��
z A A M 351 A 11,0 L 1 141
a 15M QHTFon--b
3
4
5
APPLICATION CONTINUED ON PAGE 2

Nffj-#c)c)46,7
APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
(CONTINUED FROM PAGE 1)
(7.) Do you plan to operate pumper vehicles? (check one) (\4 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? (J�yes ( ) no Initial�Date I � "I�T-('AcA
(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#: S6" 0(^ Expiration Date: l A-3I-a3 SLAS#: Expiration Date:
c) Septage Detention or Treatment Facility (SDTF Permit Numbers: (use additional sheets if needed)
SDTF#:Expiration Date: 0 -311 :2 3 SDTF#: Expiration Date: _
(9.) Septage Management Firm Operator Training Completed:
Date: I - X 7- AD, Location: 1i 4 ors Mel rG. Cron V. Ur. Hours:
Training Sponsored or Provided by: N-C/ Sep C ` &j� )-k A66L?6a4 ion
(10.) Septage Land Application Site Operator Training CompVd:
Date: I , O rq- a a Location: i Cko ra Al d -rr, n v- e-h Hours:
N 5`�-
Training Sponsored or Provided by: - ` I�7L -T&* A�lJcl A)o
(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.
Sig u (Signature of companyofcial required)
�'J2f f LM60i
Print Name
Other Comments:
11- 14
Date
O
Title
PAGE 2
Rev.04-26-2021

NC SEPT'AGE MANAGEMENT, FIRM
Recertification of Pumper Vehicle(s)
Septage Firm Permit #: NCS- 5 %
Number of Pumper Vehicles: a`N
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."
JAL�AOPU
$ignat re { lgnature of company official requireq
J2 W wuj6b n
Print Name
Date
6, wner
Title
S:lSolid WastelclalseptagelformslPumper Vehicles Cetification.doc

AUTHORIZATION To TO A► WASTMATER TREATMENT FAciLl'ry
North Carolina uepartment of Environment anti Natural howurces
Division of Wasto Management Sollid Wasta Section
1649- Mail Service Center, galeigh, NC 27699-1646
Fob ass ssmnrits anti writ? deWerninations will be regtiirod at the dltcretion of the wasuwater
treatment facility, The facility hw" the Ultimate prerogative to teeny discharges of airy wastes to the
incoming wanewater strearn,
(I>fartit ®peratav in 1W906iislbl6 f`hOW (ORC), OW [,iehrrse Nuhilitir, Nat # of P'iel )
(Address)
_--
(phone PJumb6r) (owner/operator ofSeptage Management Firi,) - --
offfj��vsttrrt�fItil8t i�iirraire�vlc-- - - - i tl5�
(5n�tage FviAiiagotrrent Off NamQ arrd NC5 riumbor)
to dispose Of: donieg it; septage x _ — • portable toilet Waste -- _
p g e ( p piirnpings) -.. ebi�mercial�iiidustriaf t; ptage horn
grease �� to ,e ream Val) - -
lhf_lir�ft�it ��l�ri►l�€�°�3�i�i�f��t�.�iitti�fi�
(C.oWAY Or other Geographic area)
at the above named wastewater treatment facility, Septage shall be discharged at.,
�rc�ie fliln�i�e �iVa�tevy�ted Xac�litlr
-
between the hours of6F00 a.m tiptil
eiri�irodatcing partially treat r! liquid into n grease trap Is aecepta ie os X _Nd
This authodiatien shall be valid until-
(ilsaaily 06eember 9%, Year)
Sighed i�ate�
�i;citiky Orst®r)
Subscribed and affirmed before me this day of 04U 40 S' gp
Pity Cvrnmission errpiraso
pia= I art)
(Notary Public)
6i6iery pubfi6, F 6ah ciroiwi OFFICIAL SEAL
�- �,r� I§9y� f; i�B{6fl l�7piF4ig
w6fe; Falgifleatiaii of thrg d'dt-U4idijt bVthe isept'ag sWi it �d �eriiu t r�vocdt vnr
J bird__ i�V�§t6/�[1y�i {3Tf i% 1tdAa/ l pirw)i A00jj65V6ii/WWTP i4rriFi 4366fi P&M i6W

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.
r 1
I,
/� 2 i
(Plant Operatorin Rdponsible Charge (ORC), ORC License Number, Name of Plant)
(Address)
c
6330 59/- 5T J9 do hereby authorize eAn LAW6 o n
(Phone Number) (Owner/Operator of Septage Management Firm)
of AT �T n l )w)-hC InC �rv(Ck-1 Ncs#Ob' .5
Management Firm Name and N�S number)
to dispose of: domestic septage V/ , portable toilet waste
grease septage (grease trap pumpings) commercial/industrial septage _ , from
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
(Location)
between the hours of Pei Im-
Reintroducing partially treated liquid into a grease trap is acceptable Yes X 22No
This authorization shall be valid until I � - 3 l - d� a �-h 1 a - J � L
(Usually December 31, Year)
Signed Date Gf _ CO
(Facility Operator)
Subscribed and
^affirmed before me this day of .iVpvCm her . 20 ZZ
4" rX4e_4L My Commission expires:
(Nota ublic) ��111111,�ei
(OFFICIAL SEAL)-' ��: NOT • •••��
�= ,q,,
�`J'��• PUBLIC
Note: Falsification of this document by the septage management firm shall lead to permit revocation. O, •, V
S:/Solid_Waste/CLA/SEPTAGE/FORMS/2018 Firm Application/W WTP Authorization Form 2018 CpUN,�`�`

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