Disposal Authorization Form_SLAS_Fillable

AUTHORIZATION TO DISCHARGE SEPTAGE – SEPTAGE LAND APPLICATION SITE –
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). The site will be operated in accordance with 15A NCAC 13B
.0800 – Septage Management Rules.

This form is used by a land application site permit holder to indicate that permission has been given to a permitted Septage Management Firm to land apply septage on the permit holders’ land application site. I, _________________________________________________________________________________ of (Site Operator) _____________________________________________________________________________________
(Operator Address) do hereby authorize ____________________________________________________________________ (Owner/Operator of Septage Management Firm) of _________________________________________________________________ NCS # ___________ (Septage Management Firm Name) (NCS Number) to use septage disposal site SLAS # _________ for the disposal of _______ gallons of the following types of septage*: ______ domestic septage, _______ portable toilet waste septage, ______ grease septage, and / or ______ commercial/industrial septage in 20___. 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: _______________