NCS01422_2021Permit_Initial

2021
Permit and Registration

HHM Porta Toilet
is hereby issued a Septage Management Firm Permit, Permit Number NCS-01422
And by virtue of completing the annual training
requirements is hereby registered as a Portable Sanitation &
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. Warren County WWTP, Warren NC 2. Tar River Regional WWTP, Rocky Mount NC 3. South Hill WWTP, South Hill VA
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
HHM Porta Toilet
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-01422
Enter the five digits following the NCS #
City
LA CROSSE
State / Province / Region
VA
Postal / Zip Code
23950
Country
United States
Street Address
556 EAST PINE STREET
Address Line 2
Out-of-State
Yes No
4347746479
[e-mail]
Owner Info
Shannon Crutchfield
Yes No
4347744066
Operator Info
Joseph Curtis Service Technician
Yes No
4347746479
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 **
Type and amount of septage pumped in the last 12 months
0
120,000
0
0
0
North Carolina counties of operation
Warren, Halifax, Northampton, Franklin, Vance, Granville, Nash
Vehicle Info
Yes No
12/12/2020
Owner
Add vehicles
individually
Upload List
Portable Toilet Waste TX315-926 3C7WRNBLXJG279901 1,200
Portable Toilet Waste UA54-293 3C7WRNBL6KG664678 1,200
Portable Toilet Waste UA82-863 2NP2HM6X0LM682908 2,000
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Yes No
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:
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**
South Hill Regional Wastewater
Treatment Plant
12/31/2021 SH WWTP
2021.pdf
314.66…
Warren County Wastewater Treatment
Plant
12/31/2021 Warren County
WWTP 2021.pdf
358.44…
Tar River Regional Wastewater
Treatment Plant
12/31/2021 Tar River
Regional WWTP
2021.pdf
1.42MB
Yes No
Yes No
Yes No
Septage Management Firm Operator Training Completed
12/5/2020 4
Grantsboro, NC
NC Pumper Group & NC Portable Toilet Group
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
Need Inspection:
2019 Dodge 5500
2020 Peterbilt
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.
12/12/2020
12:24:20 PM
Shannon Crutchfield Owner
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: 20102410425151
Payment Date: 10/24/2020
Posting Date: 10/24/2020
Billing Information: HHM Porta Toilet LLC 556 EAST PINE STREET LA CROSSE, VA 23950 4347744066 [e-mail]
Payment Amount: 550.00 USD
Account #:
Page 1 of 1
Routing #:
Account Type: Checking
Reference Information: NCS-01422-2021,23950,HHM Porta Toilet,556 East Pine Street,LaCrosse, VA,NCS-01422,$550.00
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 10/28/2020