NCS00704_2023Permit_Initial

2023
Permit and Registration
Davidson County Schools
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-00704
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. Lexington Regional WWTP, Lexington, 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.
Digitally signed by
Wm PerrywmPerrySugg
Sugg D0:361O2O0006
Perry Sugg, Environmental Compliance Branch Head

M
APPLICATIG-N FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
DIVISION OF WASTE MANAGEMENT - SOLID WASTE SECTION -1646 MAIL SERVICE CENTER,
(1.) H name: (The "Firm name"
-Oc� U6&)(.:.n
Street address of office: _ r
City: L '�X/0 v-
Mailing address (if different):
City: L. QA IV) . It k
Phone: 7 q - 6-7 b
Ll-
E-Mail: i 0-t', .S 1 L )
be as it is
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on your vehicle(s)).
r
State:/VC- Zip: a 64
O D G 7 s�$
_State: Zip(( � ���L
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Fax: 336 l��1 `,�q 1
�a a 4 6on f k0 - rlc. 6 U s
27699.14,
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County: ( ` ' v1 Septage Management Firm permit number: NCS #
(2.) Firm owner's name:':7D au t d Ep[.y1 - cr 04A
Mailing address (if different): /�[ } 7
t L
City: State: / 0 l.�Zip (� J r
Phone:= —? L • `WJ 40 0 - Fax: �� V ` �� �-�'� ` qi `t
(3.) Firm operator's name: M 1 G t y Cf' f' 1 ��� Firm operators title: W 0a<5'�{.l.kL4ei—
Mailing /address (if different): P L) X
City:_ G ex l" C; 1 State: N �- Zip: 4�
Phone: jE. , 9 q' q . (076 S -= Fax: 3 -2, LY`Q
(4.) Type(s) of septage pumped: Write in the number of gallons numoed in last 12 months (Example: Domestic: 50,000).
Domestic TPortable Toilet Waste J^Grease (Restaurant) Treatment Plant industriallCommercial
(5.) N.C. Counties of Operation: Dow 1 we"-2caq cz� a26
(List each county you are authorized to do business in)
(6.) Total Number of Pumper Vehicles Operated: !
Number used for: Domestic Septage:_ Grease (restaurant): 3VM
Other: Portable Toilet Waste:
Vehicle Information: (use additional paper if needed)
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) (fires ( - `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
(8.) Septage Disposal Method: (check one)
a) Approved wastewater treatment plant: ( -,fy-es ( ) no. If yes, submit Wastewater Treatment Authorization for each
plant, as indicated in Subparagraph .0834(c)(14) of theSeptage Management Rules.
b) Septage Land Application Site (SLAS) Permit umbers: (use additional sheets if needed)
SLAS# 6' — Expiration Date: la -3i da SLAS#: Expiration Date:
/V0.7oL-r
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: i
Date: Location: h5Hours:
Training Sponsored or Provided by: N
(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 knowinglyp#ing a false statement, representation, or certification.
Other Comments:
)f companyoffic' u ) Date /
Title
PAGE 2
Rev.04-26-2021

NC SEPTAGE MANAGEMENT FIRM
Recertification of Pumper Vehicle(s)
Septage Firm Permit #: NCS- J(; `
Number of Pumper Vehicles: l
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 4((ggn­at�ureo(compahy official required)
fl
Print Name
10 -1�-��
Date
6 I+tr=CT g C) F A
Title
S:lSolid_WastelclalseptagelformslPumper Vehicles 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 wastewater stream.
(Plant Operator in Responsible Charge (ORC), CW License
(Address)
1 o ff. W VTP 919 300
Name of Plant) W `+V 3
14 C-
3-3 9J a do hereby authorize '� r ' 1, n _: O I"� In c
C--
(Phone Number) (Owner/Operator'4 Septage anagement Firm)
of _ �A V t Ck SOu-
Collt; QL1
(Septage r5 4nagement Firm Name' and NCS number)
to dispose of: domestic septage , portable toilet waste
grease septage (grease trap pumpings) commercial/industrial septage , from
Ck V'16 L rA, o
(County or otQ Geographic Air"A)
at the above named wastewater treatment facility. Septage shall be discharged at:
O •
between the hours of
Reintroducing partially treated liquid into a grease trap is acceptable Yes %JNo
This authorization shall be valid until / 2�f W 2_
(usually December 31, Year)
1 � 1
Signed— Date
(Facility Operator)
Subscribed and affirmed before me this "9441 day of NO vtm 12LIK, 20 aa
My Commission expires: txp—ce — aO& .
(Notary Public) - ---. - --
Jamie Freeman
No#arPP SEAL)
Davidson Cou , NC
Note: Falsification of this document by the septage management firm shall lead to permit revocation.
S:/Solid Waste/CLA/SEPTAGE/FORMS/2018 Firm Application/WWTP Authorization Form 2018

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North Carolina Department of Environmental Quality
Division of Waste Management INVOICE
NORTH CAROuNA Solid Waste Section
FnvlronmentalQunlfty
Division of Waste Management
To:
Joe Tysinger
Solid Waste Section
Davidson County Board of Education
1646 Mail Service Center
PO Box 2057
Raleigh, NC 27699-1646
Lexington, NC 27293 2057
Phone/Fax: [phone]
r.
Email: [e-mail]
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PATE
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Date: 09/27/2022
�;TD . 0o
Invoice #: NCS-00704-2023
Septage - Annual:
Davidson County Board of Education (NCS-00704)
PO Box 2057 $550.00
Lexington, NC 27293 2057
Number of Trucks:1
Date Due: 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, 2023.
Payment Options:
E-check Available online at https://deg.nc.gov/swpay
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 https://deg.nc.gov/swpay
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.
[G.S. 25-3-506: A $25.00 processing fee will be charged on all returned checks.]
Explanation of Invoice Amount is Based on Firm's Current Permit Status:
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 questions regarding:
Billing
Regulations or Technical Assistance
Jared Wilson [phone]
Chester Cobb [phone]
Jeffrey Bullard [phone]
More information available on the web:
North Carolina Department of Environmental Quality (DEQ) - https://deq.nc.gov
North Carolina Solid Waste Program - htts:l de .nc. ov abou division waste -man ementt/solid-waste-section
North Carolina Septage Management Program - https:/Ideq. ncnov/about/divisions!waste-management<solid -waste-secticn/special-wastes-and-alternative-
handling/senttac ee