NCS01233_2023Permit_Initial

2023
Permit and Registration
Jim Carter Septic Repair and Pumping
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-01233
o and registered as a
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NORTH
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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. Town of Forest City WWTP, Forest City, NC
2. Town of Spindale WWTP, Spindale, 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.
W M
Digitally signed
by Wm Perry
Perry
Sugg
Sugg
Date: 2023.02.23
14:53:35
-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 gag* as it is shown on your vehkle(s)).
P - - A
Mailing address (if different):
City:
State: Zip
Phone: X 4 Orf2�''�
Fax: 1VyA/e.
E-Mail:
County:_r-
Septage Management Firm permit number: NCS # 612,17
(2.) Firm owner's name:r�
Mailing address (if different):
r
City:
State: Zip
Phone:
Fax:
(3.) Firm operator's name:
C Firm operator's title: Q �_gAj
z LU
OL
Mailing address (if different):
vo
City:
State: Zip:
Phone:
Fax:
(4.) Type(s) of septage pumped: Write in the
number of gallons oumoed in last 72 months (Example: Domestic: 50,000).
Domestic I Portable Toilet Waste Grease (Restaurant) Treatment Plant Industrial/Commercial
(5.) N.C. Counties of Operation:
d C ,.—U c'►j d
(List each county you are authorized to do business in)
(6.) Total Number of Pumper Vehicles Operated: I
Number used for: Domestic Septage:
Grease (restaurant): o
Other: I
Portable Toilet Waste: _
Vehicle Information: (use additional paper if needed)
License Tag #
Vehicle Identification #
Tank Capacity
1
147 W M PrA L 5 Ef IV -2
Q
2
3
4
APPLICATION CONTINUED ON PAGE 2
PAGE 1

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
(CONTINUED FROM PAGE 1)
(7.)uDo you plan to operate pumper vehicles? (check one) ( ) yes ( ) 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." f I
Do you attest to the statement above? ( ) yes () no Initial �� C/ Date If f. �-a
(8.) 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 .0834(c)(14) of theSeptage 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:
(9.) Septage Managem nt Firm Operator Training Completed; 0to `.A e,-
Date: i 1.3 Location: Cam,; 4-rr- Hours:_ 4 _
Training Sponsored or Provided by: 1A)_ 3,, _ .Y 04 f , `,
(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: i
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 knowingly making a false statement, representation, or certification.
Sig re (Signature of companyofficial requireco
,Z3VN,�:� 4_ t.
Print Name
Other Comments:
p l3 iaj,
Date
f�w�er
Title
PAGE 2
Rev. 04-2rr2021

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.
I, Jacob Hodge (ORC) License Number# WW 1002183, Town of Forest City WWTP
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
828-248-5217
(Address)
do hereby authorize ^� wN
(Phone Number) (Owner/Operator of Septage Management Firm)
of Z-1 r-► CW+IW ,n-�-i Pw�.•�a r �- r��.; t' N_CS # v i-23.3
(Septage Management ' m Name and NCS number)
to dispose of: domestic septage X , portable toilet waste X
grease septage (grease trap pumpings) commercial/industrial septage , from
Rutherford County North Carolina
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
_ 397 Riverside Dr. Forest Citv NC. 28043
(Location)
between the hours of 7:OOAM and 3:30PM
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 LO •- 7 - a J--
(Facility Operator) s-� I '1
Subscribed and affirmed before me this o? ! day of Ddobt r , 20 as
1
My Commission expires: (Z) 03
(;tary Public) ``,````����M�Lr,s��i���
.
(OFFICIAL9�`AL�,i'� NOlq�Qi'L
=� s
Note: Falsification of this document by the septage management firm shall lead to permit revocati'4�� --. k I C
S:/Solid_Waste/CLA/SEPTAGE/FORMS/2016 Firm Application/WWTP Authorization Form 2016 ��//J��,,COO
� ��l

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.
e %���h er 9PY3Oil T-6L '::4
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
3a 7 sILre- t s, "- L, Ar _ tti L 'q c,
(Address)
do hereby authorize C_C'-t_r'
(Phone Number) LL (Owner/Operator of Septage Management Firm)
of Cc; 4,e;, �, rr, S Ti L W d (: c,. i ,, NCS # b ( �
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage / r portable toilet waste ,
grease septage (grease trap purY pings) commercial/industrial septage , from
C1�vz✓'1 � �� f5� � �r f'if',� p
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
(Location)
between the hours of `u.� r'i+"y F., v,; 2
Reintroducing partially treated liquid into a grease trap is acceptable Yes -V< No
This authorization shall be valid until 12 %/ AP 013
(Usually December 31, Year)
Signed
(Facility Operator)
Subsc ibe ffirmed before me t is
r.
(Notary Public)
Date » / )2 L_
My Commission expires:
Note: Falsification of this document by the septage management firm shall lead to p
S:/Solid_Waste/CLA/SEPTAGE/FORMS/2018 Firm Application/WWTP Authorization Form 2018
[00n&�_20�

NC SEPTAGE MANAGEMENT FIRM
Recertification of Pumper Vehicle(s)
Septage Firm Permit #: NCS- f3
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."
h 3 1
Sign (Signaturre(' of company official required) Date
�QYhP.j JTs Le01-i'
Print Name Title -
S:1Solid WastelclalseptagelformslPumper Vehicles Cetification.doc