Firm Permit Application

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
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DIVISION OF WASTE MANAGEMENT - SOLID WASTE SECTION – 1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646 (1.) Firm name: (The “Firm name” must be exactly as it is shown on your vehicle(s)).
Street address of office:
City: State: Zip:
Mailing address (if different):
City: State: Zip
Phone: Fax:
E-Mail:
County: Septage Management Firm permit number: NCS #
(2.) Firm owner's name:
Mailing address (if different):
City: State: Zip
Phone: Fax:
(3.) Firm operator's name: Firm operator’s title:
Mailing address (if different):
City: State: Zip:
Phone: Fax:
(4.) Type(s) of septage pumped: Write in the number of gallons pumped in last 12 months (Example: Domestic: 50,000). Domestic Portable Toilet Waste Grease (Restaurant) Treatment Plant Industrial/Commercial

(5.) N.C. Counties of Operation:
(List each county you are authorized to do business in) (6.) Total Number of Pumper Vehicles Operated: Number used for: Domestic Septage: Grease (restaurant): Other:
Vehicle Information: (use additional paper if needed)
Portable Toilet Waste:
License Tag # Vehicle Identification # Tank Capacity 1
2
3
4
5

APPLICATION CONTINUED ON PAGE 2
APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
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(CONTINUED FROM PAGE 1) (7.) Do you plan to operate pumper vehicles? (check one) ( ) yes ( ) no. If you checked yes above, you must attest to the following statement before a permit may be issued. "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 .0835(a) and vehicle lettering as required by 15A NCAC .0835(b). Furthermore, I also certify that a log is maintained of each septage pumping event as required by 15A NCAC 13B .0836(a). I am aware that there are significant penalties for false certification including the possibility of fine and imprisonment." Do you attest to the statement above? ( ) yes ( ) no Initial Date (8.) Septage Disposal Method: (check one) a) Approved wastewater treatment plant: ( ) yes ( ) no. If yes, submit Wastewater Treatment Authorization for each plant, as indicated in Subparagraph .0834(c)(14) of the Septage Management Rules. b) Septage Land Application Site (SLAS) Permit Numbers: (use additional sheets if needed) SLAS#: Expiration Date: SLAS#: Expiration Date:

c) Septage Detention or Treatment Facility (SDTF) Permit Numbers: (use additional sheets if needed) SDTF#: Expiration Date: _ SDTF#: Expiration Date:
(9.) Septage Management Firm Operator Training Completed: Date: Location: Hours:
Training Sponsored or Provided by:

(10.) Septage Land Application Site Operator Training Completed: Date: Location: Hours:
Training Sponsored or Provided by:
(11.) Registration type requested: CHECK ONE
Registered Portable Sanitation Firm: ______
Registered Septage Management Firm: ______
Registered Portable Sanitation and Septage Management Firm: _____
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.
Signature (Signature of company official required) Date Print Name Title Other Comments:
Rev. 04-26-2021