New Submission

For questions regarding this form or the online application process, please contact Jeffrey Bullard (919-707-8285) or Chester Cobb (919-707-8283).

Firm Info

Firm name*field type single line
The "Firm name" must be exactly as it is shown on your vehicle(s).
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Septage Management Firm permit number (NCS #)*field type single line
Enter the five digits following the NCS #
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Street address of office*field type address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
County*field type drop-down
Mailing address same as street address of office?*field type radio button
Mailing address same as street address of office?YesNo
Mailing Address*field type address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Phone*field type single line
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Faxfield type single line
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Email*field type email

Owner Info

Firm owner's name*field type single line
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Mailing address same as street address of office?*field type radio button
Mailing address same as street address of office?YesNo
Mailing Address*field type address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Phone*field type single line
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Faxfield type single line
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Operator Info

Firm operator's name*field type single line
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Firm operator's titlefield type single line
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Mailing address same as street address of office?*field type radio button
Mailing address same as street address of office?YesNo
Mailing address*field type address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Phone*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Faxfield type single line
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Approximate amount of Grease Septage managed within the last 12 months
Amount in gallons*field type number
Grease (Septage) Amount in gallons*field type number
Add

	Amount in gallons*field type number
Grease (Septage)	Amount in gallons*field type number

North Carolina counties of operation

List each county you plan to do business in:*field type multi line

Vehicle Info

Do you plan to operate pumper vehicles?*field type radio button
Do you plan to operate pumper vehicles?YesNo
Stop filling out this form. If planning to operate pumper vehicles, you must submit a Septage Management Firm Application.

Procedure to Clean an Interior Point-Of-Use Grease Interceptor

Please read the following procedure and and check the box acknowledging you have read the procedures.

Note: Interceptor must be cleaned when the sinks are not being used and no food preparation is taking place. Do not VIOLATE any Health Department Regulations.
1. Obtain proper tools to open the interceptor.
2. Place plastic trash bags (or any disposable item) on floor to protect floor from contamination.
3. Remove lid from interceptor and place upside down on floor protection item.
4. Skim grease from top of interceptor and place in a container lined with two strong disposable bags.
5. Scrape walls of the interceptor with a wide putty knife or similar item to remove solids and grease that have accumulated on the walls.
6. Remove solids from the bottom of the interceptor and place in the same container with the grease skimmings.
7. Inspect the trap for any equipment deficiencies and make repairs.
8. Place lid on interceptor carefully. Make sure lid is sealed properly or odors will be released.
9. Place floor covering item in the trash dumpster.
10. Remove container with grease and solids from the food preparation area.
11. Solidify contents with an absorbent material such as kitty litter. Make sure all contents are solidified. This may take several minutes for the material to absorb all of the liquid.
12. Tie bags together securely.
13. Inspect bag for leaks and re-bag if needed.
14. Place bag in trash dumpster.
15. Clean the area and sanitize all surfaces in the areas as prescribed by the Health Department.
Acknowledgement*field type checkbox
AcknowledgementI acknowledge I have read the procedure to clean an interior point-of-use grease interceptor.

Septage Management Operator Training

Indicate which type of training you have completed.*field type radio button
Indicate which type of training you have completed.In-person trainingOnline training

In-person Training

Date*field type date
Hours*field type number
Location*field type single line
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Training Sponsored or Provided by*field type drop-down

Online Training

In accordance with North Carolina General Statute 130A-291.3(a) requiring septage management firm operators to attend a training course approved pursuant to subsection (d) of said section of no less than four hours of instruction per year, I certify that I have met my septage management firm permit annual training requirements. Furthermore, I certify that the following person(s) have completed the requisite four (4) hours of training via the online N.C. Division of Waste Management Solid Waste Section's presentations/training developed specifically for restaurants which have applied for or are renewing a North Carolina Septage Management Firm Permit:
Person(s) completed training:
×
- Name*field type single line
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- Position/Title*field type single line
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- Date of training*field type date
+ Add another person

Registration Type

Select one*field type radio button
Select oneRegistered Septage Management Firm

Comments and Notes

Comments or notesfield type multi line

Certification Statement

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.

Signature*field type signature
Datefield type date
Print Name*field type single line
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Title*field type single line
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Application for Permit to Operate a Restaurant Septage (Grease) Management Firm