NCS01047_2023Permit_Initial

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NORTH CAROLINA
Environmental Quality
2023
Permit and Registration
Keith Roberts Septic Sewer & Drain Inc.
is hereby issued a Septage Management Firm Permit,
Permit Number NCS-01047
and registered as a
Septage Management Firm
(PUMPER)
in the State of North Carolina.
PlORTH CAROLiNA �EQ
wll�pl
Department of Environmental Quality
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. Clark Creek WWTP, Newton, NC
2. City of Hickory WWTP, Hickory, 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
Perry
Wm PerrySugg
Date: 2023.02.23
Sugg
14:20:28-05'00'
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 exactly as R is shown on your vehicle(s)).
Street address of office: 3K71 - r
City:
Mailing address (if different):
City:
State: AX- Zip: S-z�Co �
State: Zip:
Phone: 2� S-'7W - !ZZ! .j Fax:
E-Mail: Q-fIgfi 69-Ll
County: Septage Management Firm permit number: NCS # o1D�it7
(2.) Firm owner's name:
Mailing address (if different):
City:
State: Zip:
Phone: Fax:
(3.) Firm operator's name: /4*y� z . Jim Firm operator's title: r
Mailing address (if different):
City: State: Zip:
Phone: Fax:
(4.) Type(s) of septage pumped: Write in the number of gallons pumped in last 12 Months (Example: Domestic:
50,000).
Domestic Portable Toilet Waste Grease (Restaurant) _ Treatment Plant 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:
Number used for: Domestic Septage: i
Other:
Vehicle Information: (use additional paper if needed)
Grease (restaurant):
Portable Toilet Waste: 1
License Ta #
Vehicle Identification #
Tank Capacity
1
17
-t Ga/n rFf-3
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.) 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 .0833(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:
(8.) Septage Management Firm Operator Training Completed:
Date: &Ak Location: AGAV- ii✓
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:
Registered Portable Sanitation and Septage Management Firm:
Certification Statement
Hours:
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.
'1�alu 0111,414
Signature (Signs of company official required)
Print Name
Other Comments:
Date
� en�
Title
S:lSolid_Waste:ICLA/SEPTAGE/FORMS/2018 Firm Application/FirmPemitApplicaton20l8
PAGE 2

NC SF prirAGE. MANAGEMENT FIRM
Recertification of Pumper Vehicle(s)
Septage Firm Permit #: NCS- (310'4 T
Number of Pumper Vehicles:
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 (Sign re -of company official requireao
Print Name
Date
�e5rc�
Title
S:lSolid WastelcialseptagelformslPumper 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.
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(Plant Operator in Responsible Charge (ORC), ORC License/Number, Name of Plant)
� 0-7 4L�11%P -ta ;� /1 C �-�� 5 -
(Address)
do hereby authorize
(Phone Number)
(Owner/Operator of Septage Management Firm)
of 'fCIA �a7�C�'��!�iN
(Septage Management Firm Name and NCS number)
to dispose of: domestic Septage portable toilet waste
NCS# 0AD`17
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:
o Y%A- lU b e 2 5
(Location)
between the hours of 10M ynpA
Reintroducing partially treated liquid into a grease trap is acceptable Yes iv No
This authorization shall be valid until �' 2 �� 3 / s
(Usually December 31, Year)
Signed Date 1
((a ility Operator)
Subscrib d and affirmed before this day of tic 20 ��-
6y My Commission expires: S tea%
(Notary Public)
RONALD L INGRAM (0 FICIAL SEAL)
NOTARY PUBLIC
Catawba County
North Carolina
My Commission Expires May 8, 2027
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 VM Authorization Form 2018

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.
I, Shawn Pennell. City: of Hickory
(Plant Operator and Name of Plant)
4014 River Rd Hickorv_, NC 28602
(Address)
828-455-2011 do hereby authorize Keith Roberts
(Phone Number) (Owner/Operator of Septage Management Firm)
of Keith Roberts Septic, Sewer & Drain Inc. NCS # 01047
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage X _, portable toilet waste X ,
grease septage (grease trap pumpings)-------- commercial/industrial septage
Catawba. Caldwell. Iredell. Lincoln. and Burke
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
Old Brookford Plant
(Location)
between the hours of 7:00am and 7:00 m
, from
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) q
Signed Date �V (i Z v
(Faci y Operator)
Sw rn to and scribed before me this day of 20
My Commission expires:
(Notary Public)
(OFFIC' 11iflM►jj�
`erg%% S BEAt
b ���►':
Note: Falsification of this document by the septage management firm shall lead to permit revocation. t
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