NCS01163_Permit2019_Initial

2019
Permit and Registration

Premium Tanks & Stone
is hereby issued a Septage Management Firm Permit, Permit Number NCS-01163
And by virtue of completing the annual training
requirements is hereby registered as a Portable Sanitation 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. City of Roxboro WWTP
2. Septage Detention or Treatment Facility SDTF-73-01
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?**
Phone**Fax
Firm Info
Premium Tanks & Stone
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-01163
Enter the five digits following the NCS #
City
ROXBORO
State / Province / Region
NORTH CAROLINA
Postal / Zip Code
27573
Country
United States
Street Address
120 BURCH AVE
Address Line 2
Person
Yes No
City
ROXBORO
State / Province / Region
NC
Postal / Zip Code
27573
Country
United States
Street Address
PO Box 1037
Address Line 2
3365972005 3365973215
[e-mail]
Owner Info
Kippy Blanks
Yes No
3365972005
Firm operator's name**Firm operator's title
Mailing address same as street address of office?**
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
there significant penalties for false certification including the possibility of fine and imprisonment."
Signature
Date**
Title**
Choose how to add vehicle descriptions**
Pumper Vehicles
Operator Info
Kippy Blanks President
Yes No
3365972005
Type and amount of septage pumped in the last 12 months
0
60,000
0
0
0
North Carolina counties of operation
person
orange
durham
granville
Vehicle Info
Yes No
12/6/2018
President
Add vehicles
individually
Upload List
Usage*License Tag #*Vehicle Identification #*Tank Capacity*
Approved wastewater treatment plant**
If yes, list the facilities below and upload or submit by mail a copy of Wastewater Treatment Authorization for each plant as indicated in
subparagraph .0833(c)(14) of the Septage Management Rules.
Mail forms to:
NC DEQ
Division of Waste Management - Solid Waste Section
1646 Mail Service Center
Raleigh, NC 27699-1646
Wasterwater Treatment Facility Name*Expiration Date*Authorization
Septage Land Application Sites (SLAS)**
Septage Detention or Treatment Facility (SDTF)**
Other disposal method**
Date**Hours**
Location**
Training Sponsored or Provided by**
Date Hours
Location
Training Sponsored or Provided by
Select one**
Portable Toilet Waste CP4672 JALE5B14X7905899 600
Portable Toilet Waste EF9503 3C7WRMBL0DG518984 800
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Yes No
Roxboro Waste Water Treatment Plant 12/31/2019
Yes No
Yes No
Yes No
Septage Management Firm Operator Training Completed
12/8/2018 4
Raleigh
NC Pumper Group & NC Portable Toilet Group
Septage Land Application Site Operator Training Completed
0
Registration Type
Comments or notes
Signature
Date
Print Name**Title**
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.
12/6/2018
08:56:51 AM
Kippy Blanks President