NCS00309_2023Permit_Initial

2023
Permit and Registration
Clark's Septic Tank Service
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-00309
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. Town of Siler City WWTP, Siler City, 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.
Wm Perry Digitally signed by
Wm Perry Sugg
Sugg 113:05 01 050'00'2
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
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Street address of office: Z 6 G 012
rity Si I P_ Y e / Au
rijvMPf'-as it is shown on your vehicle(s)).
.7�1^(/lr
file-� err
Mailing address (if different): L%/ &y
City: S� h�� T tI State: %V
Phone: 7 / y (/Z / Fax:
E-Mail: A. 1. ���k � �W /u/� ; 1-/Nk , &e-
_Zip:2`7�
U C. -i
County: CYh hi Septage/Management Firm permit number: NCS # ua3yg
(2.) Firm owner's name: J r
Mailing address (if different): e—
City: State: Zip
Phone:
(3.) Firm operator's name: 'YtF' L
Mailing address (if different): .SUM
City: --
Phone:
/#rk Firm operator's title: oGJ�e
State: Zip:
Fax:
(4.) Type(s) of septage pumped: Write in the number of gallons oumoed in last 12 months (Example: Domestic: 50,000).
Domestic I Portable Toilet Waste J Grease (Restaurant) I Treatment Plant I Industrial/Commercial
(5.) N.C. Counties of Operation:
(List each county you are authorized to do business in)
(6.) Total Number of Pumper Vehicles Operated: ®/Ue
Number used for: Domestic Septage: Grease (restaurant):
Other: Portable Toilet Waste:
Vehicle Information: (use additional paper if needed)
License Tag #
Vehicle Identification #
Tank Capacity
1
5 `I l
/ .443 41-J` -:�- 3
/00
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) (Y-lfyes ( ) 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? (%Iyes ( ) no Initial A 1, C� Date /2 - / 2 - Z o 1--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 Com�,let�d:
Date: ' Z — 3 — Z� � Location: 1� ¢ /ei � I V e � Hours:
Training Sponsored or Provided by: ��+ �• am,oe-k u d
(10.) Septage Land Application Site Operator Training Completed:
Date: Location:
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
Hours:
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 (Signature of companyofficial required)
Print Name
Other Comments:
Date
4e—,( _
Title
Rev. 04-26-2021
PAGE 2

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.
Brittany York, 1007288, Town of Siler City
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
PO Box 769, Siler City, NC 27344
(Address)
919 742-4581 do hereby authorize Bruce and Marl Clark
(Phone Number) (Owner/Operator of Septage Management Firm)
of Clark Septic Tank Service NCS # 00309
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage X portable toilet waste X
grease septage (grease trap pumpings) No
Chatham County
commercial/industrial septage No , from
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
Headworks
between the hours of
(Location)
Mon - Fri 7:00 am - 4: 0 pm
Reintroducing partially treated liquid into a grease trap is acceptable Yes X No
This authorization shall be valid until Dec. 31 2023
(Usually December 31, Year)
Signed Date
(Facility O rato )
Subscrib affirmed before me this day of 20 r
My Commission expires:
(Notary Public)f19B9dOBeee°
o�QyF�y�`op,RY,rO`�
m % 20 U
Note: Falsification of this document by the septage management firm shall lead to perj)1t-4AAcat!Ad56"
S:/Solid_Waste/CLA/SEPTAGE/FORMS/2018 Firm Application/WWTP Authorization Form 2018

.'
0
North Carolina Department of Environmental Quality
Division of Waste Management INVOICE
NORTH 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:
Clark's Septic Tank Service (NCS-00309)
260 Charlie Cooper Road
Siler City, NC 27344
Number of Trucks:1
To: Bruce Clark
Clark's Septic Tank Service
260 Charlie Cooper Road
Siler City, NC 27344
Date: 09/27/2022
Invoice #: NCS-00309-2023
$550.00
Date Due: 1 12/15/2022
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 2fre-3
Payment Options:
E-check Available online at httos•//deq nc aov/swnav
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 https7//deq nc aov/sweav
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.
jG.S. 25-3-506: A $25.00 processing fee will be charged on all returned checks.]
Ex lanation of Invoice Amount is Based on Firm's Current PermitStatus:
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 auestions re ar in :
Billing
Regulations or Technical Assistance
Jared Wilson [phone]
Chester Cobb [phone]
Jeffrey Bullard [phone]
More information available on the b:
North Carolina Department of Environmental Quality (DEQ) - https://deq.nc.gov
North Carolina Solid Waste Program - hUps:/./deu,ncQQviabouions/wage-manacer*nent/solid-waste-section
North Carolina Septage Management Program - h s d .nc. owabou division waste -mans emen solid-waste-sectio 's pecial-wastes-and-alternative-
handlina/septage