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Home My WebLink AboutNCS01093_2020Permit_Initial 2020 Permit and Registration Carolina Septic, Inc. is hereby issued a Septage Management Firm Permit, Permit Number NCS-01093 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. Archie Elledge Wastewater Treatment Plant, Winston-Salem N.C. 2. Septage Detention or Treatment Facility SDTF-34-02 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 Carolina Septic, Inc. The "Firm name" must be exactly as it is shown on your vehicle(s). NCS-01093 Enter the five digits following the NCS # City Kernersville State / Province / Region NC Postal / Zip Code 27284 Country United States Street Address 330 Pineview Drive Address Line 2 Forsyth Yes No 3369935633 3369933474 carolinaseptic@gmail.com Owner Info Richard & Linda Elmore Yes No 3369935633 3369933474 Operator Info F Mark Stone VP/GM Yes No 3369935633 3369933474 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** Upload vehicle list** 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: Type and amount of septage pumped in the last 12 months 1,300,000 0 1,150,000 0 900,000 North Carolina counties of operation Forsyth, Guilford, Surry, Stokes, Randolph, Alamance, Yadkin, Davie, Davidson, Rockingham Vehicle Info Yes No 12/12/2019 VP/GM Add vehicles individually Upload List You can upload a file with a list of vehicles to be used. Please be sure to include the following information for each vehicle on your upload: Usage, License Tag #, Vehicle Identification #, and Tank Capacity. Truck Information List 2019.xlsx 8.97KB Septage Disposal Method For each method, indicate whether you plan to use it by checking yes or no. Yes No 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)** 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** Archie Elledge 12/31/2020 Archie Elledge Permit.pdf 838.23… Yes No Yes No SDTF-34-02 12/31/2020 SDTF Authorization Form 2020_Carolina Septic.doc 33KB Yes No Septage Management Firm Operator Training Completed 10/29/2019 10 Greensboro NC Septic Tank Association 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. 12/12/2019 03:10:37 AM F. Mark Stone carolinaseptic@gmail.com AUTHORIZATION TO DISCHARGE SEPTAGE AT A SEPTAGE TREATMENT OR STORAGE FACILITY PERMITTED TO SOMEONE OTHER THAN YOURSELF (This form is used by a detention or treatment facility permit holder to indicate that permission has been given to a permitted Septage Management Firm to discharge septage into the permit holders detention or treatment facility.) I, Rodney Sides (Environmental Relief Technology, Inc. (Facility Operator) 617 Waughtown Street, Building 350, Winston-Salem NC 27107 (Operator Address) do hereby authorize: Mark Stone (Owner of Septage Management Firm) Carolina Septic Inc. NCS # 01093 (Name of Septage Management Firm) 330 Pineview Drive, Kernersville, NC 27284 (Address of Septage Management Firm) to utilize septage detention or treatment facility # 34-02 for the treatment or storage of septage * in 2020 . The facility will be operated in accordance with the Septage Management Rules **. Date: 12/1/19 Signed (Facility Operator) * As defined in G.S. 130A-290(a)(32) ** As defined in 15A NCAC 13B .0800 Return the properly completed form to: North Carolina Department of Environment and Natural Resources Division of Waste Management Solid Waste Section 1646 Mail Service Center Raleigh, NC 27699-1646 Truck No. Tag Vin Capacity Usage 2 YA010799 2FZHAJBA8YAG94082 2000 Septage & Grease 3 YA104901 2FZHAZAS71AH48132 2500 Septage & Grease 4 YA013426 FFZHAZCV27AY74461 3600 Septage & Grease 5 YA122411 5PVNV8JM3G4S50956 2000 Septage & Grease 6 YA01J426 2FZHAZCV27A474461 3600 Septage & Grease PayPoint Payment Receipt Application: Solid Waste Merchant: NDENR-Solid Waste Merchant City/State: Raleigh, North Carolina Payment Status: Settled Result Message: Payment completed and settled successfully. Confirmation Number: 19121257831757 Payment Date: 12/12/2019 Posting Date: 12/12/2019 Billing Information: Carolina Septic 330 Pineview Drive Kernersville, NC 27284 3369935633 carolinaseptlc@gmall .com Payment Amount: 800.00 USD Page 1 of 1 Account Type: Checking Reference Information: NCS-01093-2020,27284,Carolina Septic Inc.,330 Pineview Dr,Kernersville,NC,NCS-01093,$800.00 Disclaimer: No convenience fee is charged for using the eCheck payment method. However, a processing fee of $25.00 or 10% of the amount of the eCheck, whichever is greater, will be charged for an eCheck returned due to insufficient funds. Payments are null and void If payment is made with an eCheck that is returned unpaid by the bank. https :/ /admin. thepayplace.com/epayadmin/paymentreceipt.aspx 12/16/2019