NCS00776_2023Permit_Initial

2023
Permit and Registration
Forsyth Rooter Service Inc
is hereby issued a Septage Management Firm Permit,
STATE,,
� Permit Number NCS-00776
- o and registered as a
--�� Septage Management FirmCAROL] � �nffi��NOR Ity
i2. ��
LULAH
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, Tide 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. Archie Elledge WWTP, Winston-Salem, NC
2. Septage Detention or Treatment Facility, SDTF-34-06, SDTF-60-09
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 Perr Digitally signed by
PerryWm Perry Sugg
Sugg
114 13 36- 05''00'7
Perry Sugg, Environmental Compliance Branch Head

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
(1.
DIVISION OF WASTE MANAGEMENT - SOLID WASTE SECTION -1646 MAIL SERVICE CENTER, . ALE43HjjC 276 1646
Firm name: (The "Firm name" must be exactly as it is shown on your vehkie(313L Na $'221r
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Street address of office:
City:_ — Q State: MC, Zip:
Mailing address (if different): _ P C) J�j 0K a 4 aL q B
City: U)1 ASAyn — m"S('�...�,£ lv\. State: i�. Zip: CU 1 14 — qof q
Phone: Fax:%
E-Mail: 7� Lk -LA .I, "2.@ 1 r , r 1rC _5..1:
County: :R C QqA3 Septage Management Firm permit number: NCS # 00774o
(2.) Firm owner's name:_ e e— T . � e �,_ SL _-
Mailing address (if different):
City:
Phone:
(3.) Firm operator's name:
Mailing address (if different):
City:
State: Zip:
Fax:
Firm operator's title:
State: Zip:
Phone: Fax:
(4.) Type(s) of septage pumped: Write in the number of gallons pumped in 2015 (Example: Domestic: 50,000).
Domestic Portable Toilet Waste Grease (Restaurant) Treatment Plant I Industrial/Commercial
(5.) N.C. Counties of Operation:
(List each county you do business in)
(6.) Total Number of Pumper Vehicles Operated: _
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
7
2
3
4 Lf0
-
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4
40
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5
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APPLICATION CONTINUED ON PAGE 2
PAGE 1

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
(CONTINUED FROM PAGE 1)
(7.) Septage Disposal Method: (check one)
a) Approved wastewater treatment plant: yes no. If yes, submit Wastewater Treatment Authorization
for each plant, as indicated in Subparagrap .0833 c(4) 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:
(8.) Septage Management Firm Operator Training Completed:
Date: (� �� I _- Location: MoLA N
Training Sponsored or Provided by: �.
(9.) Septage Land Application Site Operator Training Completed:
Date: Location:
Training Sponsored or Provided by:
(10.) Registration type requested: CHECK ONE.
Registered Portable Sanitation Firm:
Registered Septage Management Firm: dz
Registered Portable Sanitation and Septage Management Firm:
Certification Statement
Hours: 14
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 company official required)
Print Name
Other Comments:
0 - 0(a 2Z
Date
Title
S:/Solid_Waste:/CLAISEPTAGE/FORMS/2016 Firm Application/FirmPermitApplication2016
PAGE 2

Winston-Salem / Forsyth County
iis
telete
�
Water * Wastewater • Solid Waste
Wastewater Division, 2799 Griffith Road, Winston-Salem, NC 27103
O: 336-727-8000, F: 336-659-4320, wsfcutilities.org
SEPTAGE DISCHARGE PERMIT
* THERE SHALL BE NO GREASE DISCHARGED AT ELLEDGE WASTEWATER TREATMENT PLANT *
Permit # 4-23
Is issued in compliance with the provisions of the City of Winston-Salem Sewer Use
Resolution, subsequent revisions thereof, and any other applicable rules and regulations of
the City of Winston-Salem.
Forsyth Rooter Service
2960 Griffith Road
Winston-Salem, NC 27103
is hereby authorized to discharge Domestic Septage into the designated disposal site
located at the -
Elledge Wastewater Treatment Plant
2801 Griffith Road
Winston-Salem, NC 27103
NPDES # NCO037834
in accordance with the limitations and conditions as set forth in this Septage Discharge
Permit.
This permit and the authorization to discharge shall become effective January 1, 2023.
This permit and the authorization to discharge shall expire at midnight on
December 31, 2022.
fL /
Signed this Z day of �G�ObP� , 2022.
�J
ae e
Citty/County Utilities
City of Winston-Salem
North Carolina
Permit Number 4-23
City Council: Mayor AllenJoines; Denise D. Adams, Mayor ProTempore, North Ward; Dan Besse, Southwest Ward; Robert C. Clark, West Ward; John C. Larson, South
Ward; Jeff Macintosh, Northwest Ward; Annette Scippio, East Ward; lames Taylor, Jr., Southeast Ward; City Manager. Lee D. Garrity
County Commissioners: David R. Plyler, Chair; Don Martin, Vice Chair, Fleming El -Amin; Ted Kaplan; Richard V. Linville; Tanya McDaniel; Gloria D. Whisenhunt; County
CaN 311 or 336-727-8000 Manager: Dudley Watts, Jr.
Winstan-Salem/Forsyth County Utility Commission: Randall S. Tuttle, Chair; L Wesley Curtis, Jr., Vice Chair, Harald E. Day; Tom Griffin; Yvonne H. Hines; Duane Long;
citylinkCcityofuvs.or0 HughW.Jernigan;ChrisParker,JamesRuffin;DonaldR.Stewart;AllanYounger

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.
Matthew Lavi ne- WW#997822-Archie Elled a Wastewater Facilitu _
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
2801 Griffith Rd. Winston-Salem, NC 27103
(Address)
336-765-0130 do hereby authorize _ Steve Newsome
(Phone Number) (Owner/Operator of Septage Management Firm)
of Forsyth Rooter Service NCS # 00776
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage _ X , portable toilet waste X _
grease septage (grease trap pumpings) NO __ commercial/industrial septage
Winston-Salem/Forsyth County and Adiacent Counties
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
Archie Elled a Wastewater Facilit
(Location)
between the hours of 6:00 am until 6:00 pm Monday Through Saturday
Reintroducing partially treated liquid into a grease trap is acceptable Yes X No
This authorization shall be valid until December 31. 2023
(Usually December 31, Year)
from
Signed Date �o N tip
(F i ity Operator)
Subscribed and affirmed before me this day of OC-*,o1xt . 20
? My Commission expires:
(Notary Public) MARY G. BROWN
-� Notary Public, North Carolina
Forsyth County (OFFICIAL SEAL)
My C mission Expires
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

AUTHORIZATION TO DISCHARGE SEPTAGE AT A SEPTAGE TREATMENT OR
STORAGE FACILITY PERMITTED TO SOMEONE OTHER THAN YOURSELF
(This form is used by a detention or treatment facility permit holder to indicate that permission has been given to a permitted
Septage Management Firm to discharge septage into the permit holders detention or treatment facility.)
i, Liquid Environmental Solutions
(Facility Operator)
Offices at 4826 Worth Place, Cha_dotte. NC 28216 and at 750 Palmer Lane: Winston-Salem, NC 27107
(Operator Address)
do hereby authorize: Steve Newsom
(Owner of Septage Management Firm)
Forsvtli Rooter INC NCS # 00776
(Name of Septage Management Firm)
PO Box 24248 Winston Salem NC 27114
(Address of Septage Management Firm)
to utilize septage detention or treatment facility # STDF 34-06 & STDF 60-09 for the treatment or
storage of septage *
in 2022-2023 . The facility will be operated in accordance with the Septage Management Rules *.
Date: 10-18-2022
Signed ,
f (Faciloperatorf
Joe Ivey erry, Processing Facility Manager
" As defined in G.S.130A-290(a)(32)
As defined in 15A NCAC 138.0800
Retum the properly completed form to:
North Carolina Department of Environment and Natural Resources
Division of Waste Management
Solid Waste Section
1646 Mail Service Center
Raleigh, NC 27699-1646

NC SEPTAGII MANAGEMENT FIRM
Recertification of Pumper Vehicle(s)
Septage Firm Permit #: NCS- O O"7 -1,1,,
Number of Pumper Vehicles: i
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."
Sig ature (Signature of company official required) Date
Print Name Title
S:lSolid_WastelclalseptagelformslPumper Vehicles Cetification.doc

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