Disposal Authorization Form_SDTF_Fillable

AUTHORIZATION TO DISCHARGE SEPTAGE – SEPTAGE TREATMENT OR STORAGE FACILITY –
North Carolina Department of Environmental Quality Division of Waste Management – Solid Waste Section 1646 Mail Service Center, Raleigh, NC 27699-1646
*As defined in G.S. 130A-290(a)(32). **As defined in 15A NCAC 13B .0800

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, _________________________________________________________________________________ of (Facility Operator) _____________________________________________________________________________________
(Operator Address) do hereby authorize ____________________________________________________________________ (Owner/Operator of Septage Management Firm) of _________________________________________________________________ NCS # ___________ (Septage Management Firm Name) (NCS Number) to use septage detention or treatment facility SDTF # _________ for the treatment or storage of the following types of septage*: ______ domestic septage, _______ portable toilet waste septage, ______ grease trap pumping septage, and / or ______ commercial/industrial septage in 20_____. The facility will be operated in accordance with the Septage Management Rules**. Signed _______________________________________________ Date _______________
_____________ County, North Carolina I certify that the following person did personally appear before me this day, acknowledging to me that he/she voluntarily signed the foregoing document: ________________________________________
Name(s) of principals(s) Date _______________
__________________________________________ Official Signature of Notary
(Official Seal) _______________________________, Notary Public Notary’s printed or type name
My commission expires: _______________