NCS00107_2021Permit_Initial

2021
Permit and Registration

Bennie A. Moore Septic Tank
Service Inc.
is hereby issued a Septage Management Firm Permit, Permit Number NCS-00107
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. Septage Land Application Site SLAS-59-02 and SLAS-59-05
2. Septage Detention or Treatment Facility SDTF-59-02 and SDTF-59-05 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, 2021.

__________________________________________________
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
BENNIE A. MOORE SEPTIC TANK SERVICE INC.
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-00107
Enter the five digits following the NCS #
City
Williamston
State / Province / Region
NC
Postal / Zip Code
27892
Country
United States
Street Address
1150 ELI BOWEN
Address Line 2
Martin
Yes No
2527925978 252-792-1074
[e-mail]
Owner Info
RUSS AYERS
Yes No
2527997461 252-792-1074
Operator Info
RUSS AYERS PRESIDENT
Yes No
2527925978 2527921074
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*
Type and amount of septage pumped in the last 12 months
477,500
0
416,000
0
0
North Carolina counties of operation
BEAUFORT-MARTIN-BERTIE-CHOWAN-TYRELL-HYDE-WASHINGTON-CRAVEN-PITT-WILSON-
GREEN-EDGECOMBE-PASQUOTANK-NASH-PERQUIMANS-CAMDEN-DARE-HERTFORD-HALIFAX-
DUPLIN-LENOIR
Vehicle Info
Yes No
11/2/2020
PRESIDENT
Add vehicles
individually
Upload List
Domestic Septage YA78060 3HAEKTOK1405450 4,100
Grease (restaurant)YA156773 3HTEKTAT7MN616479 4,200
Domestic Septage YA44344 1HTSDAAN8YH52173 2,500
Domestic Septage YA44345 1HTSDNUN8NH418138 2,100
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Approved wastewater treatment plant **
Septage Land Application Sites (SLAS)**
If you are not the permit holder for the septage land application site, you must have a signed land application authorization form for each
site.
SLAS #*Expiration Date*Authorization
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**
Yes No
Yes No
SLAS-5902 8/5/2021
SLAS-5905 8/5/2021
Yes No
SDTF-5902 10/7/2021
SDTF-5905 8/5/2021
Yes No
Septage Management Firm Operator Training Completed
10/6/2020 6
WASHINGTON
NC Septic Tank Association
Septage Land Application Site Operator Training Completed
10/6/2020 3
WASHINGTON
NC Septic Tank Association
Registration Type
Registered Portable Sanitation Firm
Registered Septage Management Firm
Registered Portable Sanitation and Septage Management Firm
Comments or notes
Signature
Date
Print Name**Title**
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.
11/2/2020
07:40:03 AM
RUSS AYERS PRESIDENT