Notice of Ceased Operation Form

State of North Carolina
Environmental Quality
Waste Management

I hereby inform the Division of Waste Management that I will not be operating as of:
*field type date
(date)
Name of Firm/Facility*field type single line
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Type of Facility*field type radio button
Type of FacilitySeptage Firm (NCS)Septage Land Application (SLAS)Septage Detention/Treatment (SDTF)
NCS #*field type single line
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SLAS #*field type single line
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SDTF #*field type single line
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Address*field type single line
(street or PO box)
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City*field type single line
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State*field type single line
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Zip Code*field type single line
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County*field type drop-down
Phone*field type single line
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Commentsfield type multi line

Certification

I certify that the information and representations in this notice are true, complete, and accurate to the best of my knowledge and belief. I am aware that there are criminal penalties for knowingly making a false statement, representation, or certification.
Signature of Owner*field type signature
Date*field type date
Date will be captured on form submission
Name of Owner*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Email of Owner or person completing this form*field type email