NCG550250_Septage Service Record_20210921

ve60-0"3-01
Winston-Salem/Forsyth County
City/County Utilities
Septage Service Record 8 1 2 1 2
Please complete a septage service record for each load discharged. List each customer's
information that comprises the total load to be discharged.Septage from Forsyth County
and adjacent counties will be accepted for treatment. Elledge WWTP is open Monday-Friday,
6 A.M.-6 P.M. For emergencies,please call 65g-4322.
S to a on inates from: 'N / /7
N Phone number
Location where septage was pumped Date
2) /, '\II4 .' i fC
�^ ame,?-,, . property own . 1 i j Phone number
(0' ke;V97
Location where septage was pumped Date
3) ,
Name of property owner Phone number
Location where septage was pumped Date
jiiHauler information:,
QrigSeptage pumped by: f` lie( �,, fir'
Name of Septage Management Fir • ,,x
Gallons of Septage pi - : rj
i ."
Date ? . y ."�
Time:
**I certify that the above information is correct,to the best of my knowledge,and that the materials
described above are not subject to Federal Regulations as hazardous waste. I agree to abide by
all conditions set forth in the City of Winston-Salem's Sewage System Policy and failure to comply
may result in a penalty of up to twenty-five thousand dollars($25,000)per day,per violation and
loss of privilege to dispose of septage at the City's receiving station. I also agree that all records and
equipment used in servicing of septage tanks is subject to inspection at any time by the City of 4;•
Winston-Salem,Utilities Depa� personnel.** a' t ''''Nt/
)J // .., bb
!/Jr/'J Signature(Septage pumper) Date
TfriV—