NCS01068_2023Permit_Initial

2023
Permit and Registration
Piedmont Disposal
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-01068
o and registered as a
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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. Archie Elledge WWTP, Winston-Salem, 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 14:24:37-05 00'3
Perry Sugg, Environmental Compliance Branch Head

For questions regarding this form or the online application process, please contact Jeffrey Bullard (919-707-8285) or Chester Cobb (919-707-
8283).
Firm Info
Firm name*
PIEDMONT DISPOSAL
The "Firm name" must be exactly as it is shown on your vehicle(s).
Septage Management Firm permit number (NCS #)
NCS-01068
Enter the five digits following the NCS #
Street address of office*
Street Address
4420 PROVIDENCE LN
Address Line 2
City State / Province / Region
WINSTON SALEM NC
Postal / Zip Code Country
27106 USA
County*
Forsyth
Mailing address same as street address of office?*
• Yes No
Phone* Fax
336-777-8805
Email*
[e-mail]
Owner Info
Firm owner's name*
JOSEPH M LONG
Mailing address same as street address of office?*
• Yes No
Phone* Fax
336-777-8805
Operator Info
Firm operator's name* Firm operator's title
TIM GARDNER CFO
Mailing address same as street address of office?*
0 Yes No

Phone* Fax
336-777-8805
Type and amount of septage pumped in the last 12 months
Amount in gallons*
Domestic
0
Portable Toilet Waste
426,109
Grease (Restaurant)
0
Treatment Plant
0
Industrial/Commercial
0
North Carolina counties of operation
List each county you plan to do business in: *
FORSYTH, GUILFORD, DAVIE, DAVIDSON, STOKES, YADKIN, ROWAN, SURRY, IREDELL
Vehicle Info
Do you plan to operate pumper vehicles?*
• Yes No
"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 significant penalties for false certification including the possibility of fine and imprisonment."
Signature
7 L�
Date*
12/13/2022
Title*
CFO
Choose how to add vehicle descriptions*
• Add vehicles individually Upload List
Pumper
Vehicles
Usage*
License Tag #*
Vehicle Identification #*
Tank Capacity*
Portable
Toilet Waste
HP1681
5PVNV8JT3D4S52967
1,000
Portable
Toilet Waste
KX8163
1FVACWD22NHNA9395
1,000
Portable
Toilet Waste
RB6815
1FVACXS21PHUG13474
1,000
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.

Approved wastewater treatment plant*
• Yes No
If yes, list the facilities below and upload or submit by mail a copy of Wastewater Treatment Authorization for each plant as indicated in
subparagraph .0833(c)(14) of the Septage Management Rules.
Mail forms to:
NC DEQ
Division of Waste Management - Solid Waste Section
1646 Mail Service Center
Raleigh, NC 27699-1646
Wasterwater Treatment Facility Name* Expiration Date* Authorization
ARCHIE ELLEDGE WASTWATER FACILITY 12/31/2023 BRN3C2AF4B91... 206.97...
Septage Land Application Sites (SLAS)
Yes • No
Septage Detention or Treatment Facility (SDTF)
Yes • No
Other disposal method*
Yes • No
Septage Management Firm Operator Training Completed
Date* Hours*
10/18/2022 4
Location*
BUR -MIL PARK 5834 BUR -MIL CLUB RD GREENSBORO, NC
Training Sponsored or Provided by*
NC Septic Tank Association
Septage Land Application Site Operator Training Completed
Date Hours
0
Location
Training Sponsored or Provided by
Registration Type
Select one*
• Registered Portable Sanitation Firm
Registered Septage Management Firm
Registered Portable Sanitation and Septage Management Firm
Comments and Notes �^
Comments or notes

Certif cation 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.
Signature
Date
12/13/2022
08:00:59 AM
Print Name* Title*
TIM GARDNER CFO

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, Matthew Lavigne- WW#997822-Archie Elled e Wastewater Facility
(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 Kevin Lon
(Phone Number) (Owner/Operator of Septage Management Firm)
of Piedmont Disposal NCS # 01068
(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 , from
Winston-Salem/Forsyth County and Ad'jacent Counties
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
Archie Elledge Wastewater Facility
(Location)
between the hours of 6:00 am until 6:00 prn 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)
Signed Date
(Fa Qperator) �}
Subscribed and affirmed before me this _ 3rci, day of © C4,o6-,r , 20 as
r � t'-x w Imo- My Commission expires:
(Notary Public)
MARY G. BROWN
Notery Public, North Carolina (OFFICIAL SEAL)
Forsyth County
My Co mis ion Expires
Note: Falsification of this document by the septage management firm shall lead to permit revocation.
S:/Solid_Waste/CLA/SEPTAGE/FORMS/2018 Firm Apphcation/WWTP Authorization Form 2018