Disposal Authorization Form_WWTP_Fillable

AUTHORIZATION TO DISCHARGE SEPTAGE
— WASTEWATER TREATMENT FACILITY/PLANT —
North Carolina Department of Environmental Quality
Division of Waste Management — Solid Waste Section
1646 Mail Service Center, Raleigh, NC 27699-1646
In the absence of an official WWTP disposal authorization issued on the WWTP company's letterhead,
this form must be completed, signed, and notarized.
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 to any wastes to the incoming
wastewater stream.
I, of
(Plant Operator in Responsible Charge (ORC), ORC License Number) (Name of Plant)
(WWTP Permit Number) (Address)
do hereby authorize
(Phone Number) (Owner/Operator of Septage Management Firm)
of NCS #
(Septage Management Firm Name) (NCS Number)
to dispose of: domestic Septage, portable toilet waste septage,
grease septage (grease trap pumpings), commercial/industrial septage from
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
(Location)
between the hours of
Reintroducing partially treated liquid into a grease trap is acceptable: Yes No
This authorization shall be valid until
Signed
County, North Carolina
(Usually December 31, Year)
Date
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) ofprincipals(s)
Date
(Official Seal)
Official Signature of Notary
Notary's printed or type name
My commission expires:
Notary Public
Note: Falsification of this document by the septage management firm shall lead to permit revocation.