NCS00336_Permit2019_Initial

2019
Permit and Registration

Powell's Septic Tank Service
is hereby issued a Septage Management Firm Permit, Permit Number NCS-00336
And by virtue of completing the annual training
requirements is hereby registered as a 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. Septage Land Application Site SLAS-42-04
2. Septage Detention or Treatment Facility SDTF-42-04
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
State of North Carolina
Environmental Quality
Waste Management
Application for Permit to Operate a
Septage Management Firm
For questions regarding this form or the online application process, please contact Jeffrey Bullard (919-707-8285) or Chester Cobb (919-
707-8283).
Firm name**
Septage Management Firm permit number (NCS #)**
Street address of office**
County**
Mailing address same as street address of office?**
Mailing Address**
Phone**Fax
Email**
Firm owner's name**
Mailing address same as street address of office?**
Mailing Address**
Firm Info
POWELL'S SEPTIC TANK SERVICE
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-00336
Enter the five digits following the NCS #
City
ROANOKE RAPIDS
State / Province / Region
NC
Postal / Zip Code
27870
Country
US
Street Address
3296 hwy 48
Address Line 2
Halifax
Yes No
City
ROANOKE RAPIDS
State / Province / Region
NC
Postal / Zip Code
27870
Country
US
Street Address
P.O. BOX 395
Address Line 2
2525372450 2525354907
[e-mail]
Owner Info
ALLIE M POWELLIII
Yes No
Phone**Fax
Firm operator's name**Firm operator's title
Mailing address same as street address of office?**
Mailing address**
Phone**Fax
Amount in gallons*
DomesticDomestic
Portable Toilet WastePortable Toilet Waste
Grease (Restaurant)Grease (Restaurant)
Treatment PlantTreatment Plant
Industrial/CommercialIndustrial/Commercial
List each county you plan to do business in:**
Do you plan to operate pumper vehicles?**
"I certify, under penalty of law, that the pumper vehicle or vehicles listed in the submitted permit application meets the requirements for safe
and sanitary transportation of septage as required by 15A NCAC 13B .0844(a) and vehicle lettering as required by 15A NCAC .0844(b).
Furthermore, I also certify that a log is maintained of each septage pumping event as required by 15A NCAC 13B .0839(a). I am aware that
City
ROANOKE RAPIDS
State / Province / Region
NC
Postal / Zip Code
27870
Country
US
Street Address
P.O. BOX 395
Address Line 2
2525372450
Operator Info
ALLIE M POWELLIII OWNER
Yes No
City
ROANOKE RAPIDS
State / Province / Region
NC
Postal / Zip Code
27870
Country
US
Street Address
P.O. BOX 395
Address Line 2
2525372450
Type and amount of septage pumped in the last 12 months
60,000
0
0
0
0
North Carolina counties of operation
HALIFAX, NORTHAMPTON, WARREN
Vehicle Info
Yes No
there significant penalties for false certification including the possibility of fine and imprisonment."
Signature
Date**
Title**
Choose how to add vehicle descriptions**
Pumper Vehicles
Usage*License Tag #*Vehicle Identification #*Tank Capacity*
Approved wastewater treatment plant**
Septage Land Application Sites (SLAS)**
If you are not the permit holder for the septage land application site, you must have a signed land application authorization form for each
site.
SLAS #*Expiration Date*Authorization
Septage Detention or Treatment Facility (SDTF)**
If you are not the permit holder for the septage detention/treatment facility, you must have a signed detention/treatment authorization form for
each site.
SDTF #*Expiration Date*Authorization
Other disposal method**
Date**Hours**
Location**
10/19/2018
OWNER
Add vehicles
individually
Upload List
Domestic Septage AP2636 1HT5DNSL4MH377183 1,800
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Yes No
Yes No
SLAS-4204 12/1/2019
Yes No
SDTF-4204 12/1/2019
Yes No
Septage Management Firm Operator Training Completed
2/1/2018 4
HICKORY, NC
Training Sponsored or Provided by**
Date Hours
Location
Training Sponsored or Provided by
Select one**
Comments or notes
Signature
Date
Print Name**Title**
HICKORY, NC
NC Septic Tank Association
Septage Land Application Site Operator Training Completed
2/1/2018 3
HICKORY, NC
NC Septic Tank Association
Registration Type
Registered Portable Sanitation Firm
Registered Septage Management Firm
Registered Portable Sanitation and Septage Management Firm
Comments and Notes
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.
10/19/2018
12:41:45 PM
ALLIE M. POWELL III OWNER
Powell’s for NCS-00336

Paid $550 electronically on 10/23/2018.

Chester Cobb