NCS01093_2023Permit_Initial

2023
Permit and Registration
Carolina Septic Inc.
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-01093
and registered as a
12 �� Septage Management FirmCAROL] � �nffi��NOR Ity
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 Perry Digitallysigned by
Wm Perry Sugg
Date: 28-0
Sugg
11'00'3
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*
Carolina Septic Inc
The "Firm name" must be exactly as it is shown on your vehicle(s).
Septage Management Firm permit number (NCS #)
NCS-01093
Enter the five digits following the NCS #
Street address of office*
Street Address
330 Pineview Drive
Address Line 2
City
State / Province / Region
Kernersville
NC
Postal / Zip Code
Country
27284
United States
County*
Forsyth
Mailing address same as street address of office?*
• Yes No
Phone*
Fax
3369935633
Email*
[e-mail]
Owner Info
Firm owner's name*
Richard & Linda Elmore
Mailing address same as street address of office?*
• Yes No
Phone* Fax
3369935633
Operator Info
Firm operator's name* Firm operator's title
Mark Stone VP/GM
Mailing address same as street address of office?*
0 Yes No

Phone* Fax
3369935633
Type and amount of septage pumped in the last 12 months
Amount in gallons*
Domestic 1,300,000
Portable Toilet Waste 0
Grease (Restaurant) 1,400,000
Treatment Plant 0
Industrial/Commercial 1 , 800,000
North Carolina counties of operation}
List each county you plan to do business in: *
Forsyth, Guilford, Surry, Stokes, Randolph, Alamance, Yadkin, Davie,
Davidson, Rockingham, Wilkes
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
6;?e; CL� ifs°
Date*
12/15/2022
Title*
VP/GM
Choose how to add vehicle descriptions*
Add vehicles individually • Upload List
Upload vehicle list*
You can upload a file with a list of vehicles to be used. Please be sure to include the following information for each vehicle on your upload: Usage, License Tag #, Vehicle
Identification #, and Tank Capacity.
Truck Information List 2023.xlsx 9KB
Septage Disposal Method,
For each method, indicate whether you plan to use it by checking yes or no.
Approved wastewater treatment plant*
0 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*
Archie Elledge
Septage Land Application Sites (SLAS)*
Expiration Date* Authorization
12/31/2022 WS 432.42...
Authorization
2023.pdf
Yes • No
Septage Detention or Treatment Facility (SDTF)
• Yes No
If you are not the permit holder for the septage detention/treatment facility, you must have a signed detention/treatment authorization form for
each site.
SDTF #*
SDTF-34-06
SDTF-60-09
Other disposal method*
Yes • No
Expiration Date*
12/31/2023
12/31/2023
Authorization
Liquid
Environmental
Authorization
2023.pdf
Liquid
Environmental
Authorization
2023.pdf
Septage Management Firm Operator Training Completed
Date* Hours*
9/20/2022 6
Location*
Statesville, NC
Training Sponsored or Provided by*
NC Septic Tank Association
Septage Land Application Site Operator Training Completed
Date Hours
0
9PAN4L'N
323.04...

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
�ew 60"
Date
12/15/2022
01:02:16 AM
Print Name* Title*
F Mark Stone VP/GM

Truck No. Tag Vin
2 YA010799 2FZHAJBA8YAG94082
4 YA013426 FFZHAZCV27AY74461
5 YA122411 5PVNV8JM 3G4S50956
6 YA01J426 2FZHAZCV27A474461
Capacity Usage
2000 Septage & Grease
3600 Septage & Grease
2000 Septage & Grease
3600 Septage & Grease

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 Charlotte NC 28216 and at 750 Palmer Lane Winston-Salem. NC 27107
+Operator Address)
do hereby authorize: Richard and Linda Elmore
(Owner of Seplage Management Firm)
Carolina Septic NCS # 01093
(Name of Septage Management Firm)
330 Pineview give Kemersville NC 27284
(Address of Septage Management Firm)
to utilize septage detention or treatment facility # STDF 34-06 & STQF 60-09 for the treatment or
storage of septage '
in 2022-2023 . The facility will be operated in accordance with the Septage Management Rules **.
r
Date: 12-15-2022 Signed
r (Facility rator)
Joe Mayberry, Processing Facility Manager
As defined in G.S. 130A•290(a)(32)
" As defined in 15A NCAC 138 .0800
Return 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

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 caul ne- WW#997822-Archie Elled a Wastewater Facilit
(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 Mark Stone
(Phone Number) (Owner/Operator of Septage Management Firm)
of Carolina Se tic Inc. NCS # 01093
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage X , portable toilet waste X
grease septage (grease trap pumpings) Na commercial/industrial septage , from
Winston-Salem Fors h Count and Ad'acent Counties
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
Archie Elled a Wastewater Facility
(Location)
between the hours of 6:00 am until 6:00 m 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
(i sty Operator)
�d
Subscribed and affirmed before me this
(Notary Public)
Date
day of C)c a b"- 20 33,
My Commi
Notary Public, North Carolina
Forsyth County
MV
Note: Falsification of this document by the septage management firm shall lead to permit revocation.
5:/Solid_Wa5.te/CLA/5EPTAGE/F0AMS/201B Firm Application/WWTP Authorization Form 2018