NCS00338_Permit2019_Initial (2)

2019
Permit and Registration

Myers Septic Tank Service LLC
is hereby issued a Septage Management Firm Permit, Permit Number NCS-00338
And by virtue of completing the annual training
requirements is hereby registered as a Portable Sanitation &
Septage Management Firm
in the State of North Carolina.

This permit to operate a Septage Management Firm is issued to the above named person, business or entity alone and is not transferable to any other person, business or entity. Firm operation shall be in accordance with the provisions of N.C. General Statute 130A-291.1 - 130A-291.3, Title 15A of the N.C. Administrative Code 13B .0800 et.seq., conditions of the permit, and representations made in the application and accompanying documents for a permit.
The permit holder is authorized to discharge septage only at the locations(s) listed below: 1. Cub Creek WWTP Wilkesboro, NC
2. North Wilkesboro WWTP North Wilkesboro, NC
This permit does not entitle the permit holder to operate a Septage Land Application Site, a Septage Detention or Treatment Facility, or any other solid waste management facility not specified herein.
Failure to operate as permitted may result in the Department suspending or revoking this permit, initiating action to enjoin the unpermitted operation, imposing administrative penalties, or invoking any other remedy as provided in Chapter 130A, Article 1, part 2 of the North Carolina General Statutes. This permit and registration expires on December 31, 2019.
__________________________________________________
Adam Ulishney, Environmental Compliance Branch Head
APPLICATION FOR PERMIT TO OPERA TE A SEPT AGE MANAGEMENT FIRM
DIVISION OF WASTE MANAGEMENT -SOLID WASTE SECTION-1646 MAIL SERVICE CENTER, RALBGH, NC 27699-1646
(1.) Arm name: (The "Rnn namen must be� as it is shown on yourvehicle(s}}./YI 'IE l<.S f Ee r:t c 111/1/ t. J" {'£.,; f Ct[' {., t..,,,(!_
Street addressotoffice: to£ WE5/ ;(JI/IN 51£€t:[
City: W ;/e,,.,f /;,oro ·state:Nv Zip:._,,AA�'VJ_'t_l) ___ _
Mailing address (if different): __ A_�_,t=--o_._K .... '1_o_!) __________ _
City: M'/l{t,5borD State: N'C-�p: ,2�6??
Phone: jj(p' f3j, S0't>Fax: ___ ..--_____ _
E-Mail: />1���./' ft,4 T Jc 7B#,c_ � r-J/J1frl r G�0
County: M 'I I::. rs Septage M�gement Rrm permit number: NCS # ()� 3 Y f"
(2.) Firm owner's name: .:Z ;(. II (_ /11 I/I:-�
Maifmg address (if different): ________________ _
City: __________ State: ___ Zip: ______ _
Phone: � 3 ?., .. 7 91/--I ;2 't "J Fax: -----------
( 3.) Firm operator'sname: 1� /11'!£"/'lS Rrm operator's title: __ _
Mailing address (if different): ________________ _
City: __________ State: ___ Zip: ______ _
Phone: _________ �Fax: __________ _
(4.) T ype{s} of septage pumped: Write in the number of qallons pumped in last 12 Months (Example: Dorneslic: 50,000).
Domestic Portable Toilet Waste Grease Restaurant Treatment Plant lndusbial/Commercial 3!"0 ()00 0� 0(')
(5.) N.C. Counties of Operation: W�'//4£ ../ �<.1£(0 IA�ttf eou �i�Ashe, Yadkin (scj)
(list each county you are authorized to do business In)
(6.) Total Number of Pumper Vehicles Operated: _....a,3..__ __ _Number used for: Domestic Septage: 3 Grease (restaurant): ___ _ Other:______ Portable Toilet Waste: __ _ Vehicle Information: (use additional paper if needed)
1 2 3 4 5
APPLICATION CONTINUED ON PAGE 2
PAGE1
APPLICATION FOR PERMIT TO OPERA TE A SEPT AGE MANAGEMENT FIRM
(CONTINUED FROM PAGE 1)
(7.) Septage Disposal Method: (check one)
a) Approved wastewater treatment plant ( /, yes ( ) no. If yes, submit Wastewater T reabnent Authorization
for each plant as indicated in Subparagraph .0833(c)(14) of the Septage Management Rules.
b)Sept.age Land Application Site (SLAS) Permit Numbers: (use additional sheets if needed)
SLAS#: ___ Expiration Date:____ SLAS#: ___ Expiration Date: ___ _
c) Septage Detention or T reabnent Facility (SDTF) Permit Numbers: (use additional sheets if needed)
SDTF#: ___ Expiration Date:____ SDTF#: ___ Expiration Date: ___ _
(9.) Septage Land Application Site Operator Training Completed:
Date: _____ Location: ______ _ Hours:
Training Sponsored or Provided by: __________________ _
(10.) Registration type requested: CHECK ONE
Registered Portable Sanitation Rnn: _ /
Registered Sept.age Management Rrm: �
Registered Portable Sanitation and Sept.age Management Firm: _
Certification Statement
I certify that the information and representations in this application for a pennit are true, complete, and accurate to
the best of my knowledge and belief. I am aware that a pennit may be suspended or revoked upon a finding that its
issuance was based upon incomict or inadequate infonnation that materially affected the decision to issue the
pennit and that there are criminal penalties for knowingly making a false statement, representation, or certification.
Signature (Signature of mpany official required)
bvfLh.bu:S Print Name ..,
Other Comments:
Date/
Title
S:JSolid_Waste:ICI.A/SEPT AGEif0RMS/2018 Fim ARllication.fimPelmilApplicalion2018
PAGE2
NCSTA 02/01/2018 (scj)
X (scj)
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