NCS01419_Permit2019_Initial

2019
Permit and Registration

Goodfellas Pizza
(Domino's Pizza)
is hereby issued a Septage Management Firm Permit, Permit Number NCS-01419
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. Material removed from an interior point-of-use grease interceptor is treated to remove any free liquids, bagged, and placed into a dumpster. Solid Waste Management Rule 15A NCAC 13B .1626(9)(c)(i) defines “free liquids” as determined by Method 9095 (Paint Filter Liquids Test) S. W. 846.
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
Restaurant Septage (Grease)
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
Goodfellas Pizza (Domino's Pizza)
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-01419
Enter the five digits following the NCS #
City
Waynesville
State / Province / Region
North Carolina
Postal / Zip Code
28786
Country
United States
Street Address
373 Walnut St.
Address Line 2
Haywood
Yes No
City
Florence
State / Province / Region
SC
Postal / Zip Code
29504
Country
United States
Street Address
P.O. Box 13225
Address Line 2
843-610-8000 843-662-6500
[e-mail]
Owner Info
Kelly Fox
Yes No
Phone**Fax
Firm operator's name**Firm operator's title
Mailing address same as street address of office?**
Mailing address**
Phone**Fax
Approximate amount of Grease Septage managed within the last 12 months
Amount in gallons*
Grease (Septage)Grease (Septage)
List each county you plan to do business in:**
Do you plan to operate pumper vehicles?**
Note: Interceptor must be cleaned when the sinks are not being used and no food preparation is taking place. Do not VIOLATE any
Health Department Regulations.
1. Obtain proper tools to open the interceptor.
2. Place plastic trash bags (or any disposable item) on floor to protect floor from contamination.
City
Florence
State / Province / Region
SC
Postal / Zip Code
29504
Country
USA
Street Address
P.O. Box 13225
Address Line 2
843-610-8000
Operator Info
Aaron Fox Franchisee
Yes No
City
Florence
State / Province / Region
SC
Postal / Zip Code
29504
Country
United States
Street Address
P.O.Box 13225
Address Line 2
843-610-7000 843-662-6500
10
North Carolina counties of operation
Haywood
Buncome
Jackson
Macon
Vehicle Info
Yes No
Procedure to Clean an Interior Point-Of-Use Grease Interceptor
Please read the following procedure and and check the box acknowledging you have read the procedures.
3. Remove lid from interceptor and place upside down on floor protection item.
4. Skim grease from top of interceptor and place in a container lined with two strong disposable bags.
5. Scrape walls of the interceptor with a wide putty knife or similar item to remove solids and grease that have accumulated on the
walls.
6. Remove solids from the bottom of the interceptor and place in the same container with the grease skimmings.
7. Inspect the trap for any equipment deficiencies and make repairs.
8. Place lid on interceptor carefully. Make sure lid is sealed properly or odors will be released.
9. Place floor covering item in the trash dumpster.
10. Remove container with grease and solids from the food preparation area.
11. Solidify contents with an absorbent material such as kitty litter. Make sure all contents are solidified. This may take several
minutes for the material to absorb all of the liquid.
12. Tie bags together securely.
13. Inspect bag for leaks and re-bag if needed.
14. Place bag in trash dumpster.
15. Clean the area and sanitize all surfaces in the areas as prescribed by the Health Department.
Acknowledgement**
Indicate which type of training you have completed.**
In accordance with North Carolina General Statute 130A-291.3(a) requiring septage management firm operators to attend a training course
approved pursuant to subsection (d) of said section of no less than four hours of instruction per year, I certify that I have met my septage
management firm permit annual training requirements. Furthermore, I certify that the following person(s) have completed the requisite four
(4) hours of training via the online N.C. Division of Waste Management Solid Waste Section's presentations/training developed specifically
for restaurants which have applied for or are renewing a North Carolina Septage Management Firm Permit:
Person(s) completed training:
Select one**
I acknowledge I have read the procedure to clean an interior point-of-use grease interceptor.
Septage Management Operator Training
In-person training Online training
Online Training
Name**
Position/Title**
Date of training**
Kelly Fox
Operating Partner
10/22/2019
Name**
Position/Title**
Date of training**
Aaron Fox
Franchisee
10/22/2019
Registration Type
Registered Septage Management Firm
Comments and Notes
Comments or notes
Signature
Date
Print Name**Title**
Made change to firm name to match name on NCDWM records JRB 10/23/2019
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.
10/23/2019
12:26:12 PM
Kelly Fox Operating Partner
PayPoint
Payment Receipt
Application: Solid Waste Credit
Merchant: NDENR-Solid Waste Credit
Merchant City/State: Raleigh, North Carolina
Merchant Location Code: 00001
Payment Status: Settled
Result Message: Payment completed and settled successfully.
Confirmation Number: 19102349113744
Payment Date: 10/23/2019
Posting Date: 10/23/2019
Billing Information: Kelly Fox P.O. Box 13225 Florence, SC 29504 8436108000 [e-mail]
Payment Amount: 550.00 USD
Card Type: VISA
Method: Not Present
Page 1 of 1
Reference Information: NCS-01419-2019,28786,Goodfellas Pizza (Domino's Pizza),1162 Sulphur Springs Rd,Waynesville,NC,NCS-01419,$550.00
Disclaimer: A convenience fee Is charged by a third-party provider for all online payments made by a credit or debit card. DEQ does not receive any portion of these fees associated with this service. The fee is currently 2.65% of the amount paid on all credit and debit card transactions, except for VISA debit, which has a flat fee of $3.95 per transaction. Your card will not be charged until after you have accepted the convenience fee amount. If you choose not to pay the fee, you may cancel the transaction and pay by another method. If you accept the convenience fee and elect to continue, your credit card statement will show two charges -one for the amount due to DEQ, and one for the convenience fee. The convenience fee is not refundable.
https://admin. thepayplace.com/ epayadmin/paymentreceipt.aspx 10/24/2019
PayPoint
Payment Receipt
Application: Solid Waste Credit
Merchant: NDENR-Solid Waste Credit
Merchant City/State: Raleigh, North Carolina
Merchant Location Code: 00001
Payment Status: Settled
Result Message: Payment completed and settled successfully.
Confirmation Number: 19102349113352
Payment Date: 10/23/2019
Posting Date: 10/23/2019
Billing Information: Kelly Fox P.O. Box 13225 Florence, SC 29504 8436108000 kellyfoxsc@aol .com
Payment Amount: 275.00 USD
Card Type: VISA
Method: Not Present
Reference Information: NCS-01419-2019LF,28786,Goodfellas Pizza (Domino's Pizza),1162 Sulphur Springs Rd, Waynesville,NC,NCS-01419,$275. 00
Page 1 of 1
Disclaimer: A convenience fee Is charged by a third-party provider for all online payments made by a credit or debit card. DEQ does not receive any portion of these fees associated with this service. The fee is currently 2.65% of the amount paid on all credit and debit card transactions, except for VISA debit, which has a flat fee of $3.95 per transaction. Your card will not be charged until after you have accepted the convenience fee amount. If you choose not to pay the fee, you may cancel the transaction and pay by another method. If you accept the convenience fee and elect to continue, your credit card statement will show two charges -one for the amount due to DEQ, and one for the convenience fee. The convenience fee Is not refundable.
https://admin.thepayplace.com/epayadmin/paymentreceipt.aspx 10/24/2019