NCS01006_2020Permit_Initial

2020
Permit and Registration

Town of Carolina Beach
is hereby issued a Septage Management Firm Permit, Permit Number NCS-01006
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. Town of Carolina Beach WWTP

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, 2020.

__________________________________________________ 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?**
Phone**Fax
Firm Info
Town of Carolina Beach
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-01006
Enter the five digits following the NCS #
City
Carolina Beach
State / Province / Region
NC
Postal / Zip Code
28428
Country
US
Street Address
1121 N Lake Park Blvd
Address Line 2
New Hanover
Yes No
9104580786 9104582997
[e-mail]
Owner Info
Town of Carolina Beach
Yes No
9104580786 9104582997
Operator Info
Mark Meyer Director of Public Utilities
Yes No
9104580786 9104582997
Amount in gallons *
DomesticDomestic
Portable Toilet WastePortable To ilet Waste
Grease (Restaurant)Grease (R estaurant)
Treatment PlantTreatment Plant
Industrial/CommercialIndustrial/Co mmercial
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 **
If yes, list the facilities below and upload or submit by mail a copy of Wastewater Treatment Authorization for each plant as indicated in
Type and amount of septage pumped in the last 12 months
0
15,706
0
0
0
North Carolina counties of operation
New Hanover County
Vehicle Info
Yes No
12/9/2019
Director of Public Utilities
Add vehicles
individually
Upload List
Portable Toilet Waste 99387-V 3D7KS28T89G533970 300
Portable Toilet Waste 22585 1FT8X3B69EEB28181 300
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Yes No
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**
Comments or notes
Town of Carolina Beach WWTP 12/31/2020 Septage 2020
WWT Auth.pdf
60.38KB
Yes No
Yes No
Yes No
Septage Management Firm Operator Training Completed
12/7/2019 4
Raleigh, NC
NC Pumper Group & NC Portable Toilet Group
Septage Land Application Site Operator Training Completed
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
Signature
Date
Print Name**Title**
the decision to issue the permit and that there are criminal penalties for knowingly making a false statement, representation, or certification.
12/9/2019
09:00:00 AM
Mark Meyer Director of Public Utilities