NCS00474_2023Permit_Initial

2023
Permit and Registration
Page's Septic Tank Cleaning
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-00474
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. Cooleemee WWTP, Woodleaf, 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 Digitally signed
by Wm Perry
Perry Sugg
Date: 2023.02.02
Sugg 13:14:11-05'00'
Perry Sugg, Environmental Compliance Branch Head

a . .
"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 exac as it is shown on your vehieWs)).
. f a jes SST'c � 1"K C lel.'.v. j —
Street address of office: 1416 A'Ala -*W, X it
City:.. f4dCf[ lc state: n/ C Zip: 70 a
Mailing address (if different):
City: --- State: Zip
Phone: 33 G . t7q VY04- Fax:
E-Mail: -
County: /Ja V r'e _ _ _ _ _ Septage Management Firm permit number: NCS # 'Y i Y
(2.) Firm owner's name:
Mailing address (if different):
City: State. Zip-
Phone:
(3.) Firm operator's name:
Mailing address (if different):
Firm operator's title:
City: _ _State: Zip:
Phone: Fax:
(4.) Type(s) of septage pumped: Writg ja tip 113IMAK ofgglions RUjWW in fast 12 months (Example: Domestic: 50.000).
Domestic
Grease (Re:
Treatment Plant
Industrial/Commercial
(5.) N.C. Counties of Operation: DAW %�erruy— lJa v,'c�Salu ` �aPr:'�i ^ �Jrcer� a/1-SAC - ya 0",A!
(Ust each county you are authoraed to do business in)
(6.) Total Number of Pumper Vehicles Operated: ;L
Number used for: Domestic Septage: aZ
Other. _ _
Vehicle Information: (use additional paper if needed)
License Tag #
ram 94/!L�
3 I..
4
'ehicle Identification #
r
Grease (restaurant):,
Portable Toilet Waste:
APPLICATION CONTINUED ON PAGE 2
PAGE

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
(CONTINUED FROM PAGE 1)
(7.) Do you plan to operate pumper vehicles? (check one) 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 133.0835(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? ( 'yes no initial {3ate ! t
(8.) Septage Disposal Method: (check one) �yes
aj Approved wastewater treatment plant: ( ( no. If yes, submit Wastewater Treatment Authorization for each
plant, as indicated in Subparagraph .0834(c)(14) of theSeptage Management Rules.
bj Septage Lad lication Site (SLAS) Pe it N hers: (use additional sheets if needed)
SLAS#: Expiration Date: SLAS#: Expi "on Date:
c) septage Deters ' or Treatment Facility ( TE} rmit Numbers: (use addit o i greets if needed)
3DTF##: Expiration Date: / SDTF#:_ Expiration Date.
(9.) Septage Management Firm Operator Training Complet d: ll
Date: [ice Location: l oft" 0 _ Hours:
Training Sponsored or Provided by:
(10.) Septage Land plicatioXSjOperator Training Completed:
Date: Location: Hours:
Training Sp6soreei or Provided by:
(11.) Registration type requested: CHECK ONE
Registered Portable Sanitation Finn:
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.
SiY.a� T r��
gnature (Signature of companyo eial required]
Ae ell/ —
Pent Name
Other Comments:
/ ILI;
Date
Title
RECEIVED
JAN 2 3 2023
SOLID WASTE SECTION
PAGE 2
Rev C4-26-20121

NC SEPTAGE MANAGEMENT FIRM
Recertification of Pumper Vehicle(s)
Septage Firm Permit #: NCS- d/7y
Number of Pumper Vehicles:_ (a)
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."
Signature (Signature of company official mquirecp
dItri Pa p
Print Name
!o ay ai8-
Date
Title
S:lSolid_WastelclalseptagelfonnslPumperVehicles Cetification.doc

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 was ater stream.
le
ptee-
(Plant O rator in Responsible Charge (ORC), ORC License Number, Name of Plant)
ol.w 14 Nc So W00411#afAn-
(Address)
3 4 _ ;J� tj G 8d do hereby authorize Ro /fit M l PN5_ e
(Phone Number) (Owner/Operator of Septage Management Firm)
of—&-geS_ SepTrC 7'aoyk L�teru; my _ _ NCS# -Y7 /
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage ✓ - _, portable toilet waste
grease septage (grease trap pumpings) N d _ commercial/industrial septage .. _ fV d , from
Em W
(County or other Geographic Area)
at the above named wastewater treatment facility. 5eptage shall be discharged at:
of /yC O( Wed-14CR P Ne 4-t Se/tee y
(Location)
between the hours of -/►� 14
Reintroducing partially treated liquid into a grease trap is acceptable Yes —4No
This authorization shall be valid until 1 - 31 - asV _
l' (Usually December 31, Year)
Signed _ Date
(F cility Operator)
Subscri �da Od affirme re me this day of V he 20
M Commission ex ires:"� Z
- Y p
(Notary Public) STACEE S DALTON
Notary Public, North Carolina
( FFICIALSEAL) Davie County
My Commission Expires
August 25, 2024
Note: Falsification of this document by the septage management firm shall lead to permit revocation.
S:/Solid_Waste/CLA/SEPTAGE/FORMS/2018 Firm Application/W WTP Authorization Form 2018