NCS01129_Permit2019_Initial

2019
Permit and Registration

Fontana Village Resort
is hereby issued a Septage Management Firm Permit, Permit Number NCS-01129
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 Detention or Treatment Facility SDTF-38-04

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?**
Phone**Fax
Email**
Firm owner's name**
Mailing address same as street address of office?**
Phone**Fax
Firm operator's name**Firm operator's title
Mailing address same as street address of office?**
Firm Info
Fontana Village Resort
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-01129
Enter the five digits following the NCS #
City
Fontana Dam
State / Province / Region
NC
Postal / Zip Code
28733
Country
USA
Street Address
300 Woods Rd
Address Line 2
PO Box 68
Graham
Yes No
828-498-2211 828-498-2209
[e-mail]
Owner Info
Fontana Village Inc.
Yes No
828-498-2211 828-498-2209
Operator Info
Brandon Jones Marina Manager
Yes No
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
Usage*License Tag #*Vehicle Identification #*Tank Capacity*
Approved wastewater treatment plant**
828-498-2129 828-498-2209
Type and amount of septage pumped in the last 12 months
0
2,032
0
0
0
North Carolina counties of operation
Graham
Vehicle Info
Yes No
1/15/2019
Controller
Add vehicles
individually
Upload List
Portable Toilet Waste NC-5153DC 27954A505 250
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Yes No
Septage Land Application Sites (SLAS)**
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**
Training Sponsored or Provided by**
Date Hours
Location
Training Sponsored or Provided by
Select one**
Comments or notes
Signature
Yes No
Yes No
SDTF-38-04 7/2/2019
Yes No
Septage Management Firm Operator Training Completed
9/15/2018 4
Asheville, NC
NC Pumper Group & NC Portable Toilet Group
Septage Land Application Site Operator Training Completed
0
Registration Type
Registered Portable Sanitation Firm
Registered Septage Management Firm
Registered Portable Sanitation and Septage Management Firm
Comments and Notes
Pumper Vehicle is a boat.
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.
Date
Print Name**Title**
1/15/2019
05:28:52 PM
Jeremiah Williams Controller
PAID (late)
FIRM NAME: Fontana Village Resort
PERMIT #: NCS-01129
AMOUNT: $550
PAID BY: e-check
DATE: 01/15/2019

Chester Cobb