NCS01275_2020Permit_Initial

2020
Permit and Registration

JW Septic Service LLC
is hereby issued a Septage Management Firm Permit, Permit Number NCS-01275
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. Mount Airy WWTP, Mount Airy NC
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
JW Septic Service LLC
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-01275
Enter the five digits following the NCS #
City
Mount Airy
State / Province / Region
NC
Postal / Zip Code
27030
Country
United States
Street Address
402 North Franklin Rd.
Address Line 2
Surry
Yes No
336-325-0899
[e-mail]
Owner Info
Jeremy williamson
Yes No
336-325-0899
Operator Info
Jeremy Williamson Owner
Yes No
336-325-0899
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
subparagraph .0833(c)(14) of the Septage Management Rules.
Type and amount of septage pumped in the last 12 months
168,000
0
29,000
58,000
158,500
North Carolina counties of operation
Surry-Stokes-Yadkin-Wilkes-Forsyth
Vehicle Info
Yes No
12/30/2019
Owner
Add vehicles
individually
Upload List
Domestic Septage EK-1229 1GDJ6H1J8TJ510292 2,000
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Yes No
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
Signature
Mount Airy WWTP 12/31/2020 image.jpg 1.95MB
Yes No
Yes No
Yes No
Septage Management Firm Operator Training Completed
1/24/2019 4
Hickory
NC Septic Tank Association
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
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**
12/30/2019
10:56:28 PM
Jeremy Williamson Owner

PayPoint
Payment Receipt
Application: Solid Waste Credit
Merchant: NDENR-Solid Waste Credit
Merchant City/State: Raleigh, North Carolina
Merchant Location Code: 00001
Payment Status: Success
R.esult Message: Success
Confirmation Number: 19123061016489
Payment Date: 12/30/2019
Posting Date: 12/30/2019
Billing Information: Jw septic service lie 402 North Franklin Rd.
Mount Airy, NC 27030 3363250899 [e-mail]
Payment Amount: 550.00 USD
Card Type: VISA
Method: Not Present
Page 1 of 1
Reference Information: NCS-01275-2020,27030,JW Septic Service LLC,402 North Franklin Rd,Mt. Airy,NC,NCS-01275,$550.00
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https ://admin. thepayplace.com/ epayadmin/paymentreceipt.aspx 12/31/2019