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Home My WebLink AboutNCS01203_2021Permit_Initial 2021 Permit and Registration Klean Latrine Septic Pumping is hereby issued a Septage Management Firm Permit, Permit Number NCS-01203 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-24-10 2. West Brunswick Regional WWTF, Supply 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, 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 Klean Latrine Septic Pumping The "Firm name" must be exactly as it is shown on your vehicle(s). NCS-01203 Enter the five digits following the NCS # City Shallotte State / Province / Region NC Postal / Zip Code 28459 Country USA Street Address PO Box 563 Address Line 2 Brunswick Yes No 910-620-5645 910-653-5242 kleanlatrine@yahoo.com Owner Info John Long Yes No 910-620-5645 910-653-5242 Operator Info John Long Owner Yes No 910-620-5645 910-653-5242 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. Mail forms to: Type and amount of septage pumped in the last 12 months 52,000 0 0 0 0 North Carolina counties of operation Brunswick, Columbus, New Hanover and Pender Vehicle Info Yes No 12/6/2020 Owner Add vehicles individually Upload List Domestic Septage YA103825 1HTSDAAN1YH276913 2,000 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)** 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)** Other disposal method** Date**Hours** Location** Training Sponsored or Provided by** Date Hours Location Training Sponsored or Provided by Select one** Comments or notes West Brunswck Regional Wastewater Treatment Facility 12/31/2021 Yes No SLAS-24-10 12/31/2020 Yes No Yes No Septage Management Firm Operator Training Completed 9/29/2020 4 Shallotte, NC NC Septic Tank Association Septage Land Application Site Operator Training Completed 9/29/2020 3 Shallotte, NC NC Septic Tank Association Registration Type Registered Portable Sanitation Firm Registered Septage Management Firm Registered Portable Sanitation and Septage Management Firm Comments and Notes Signature Date Print Name**Title** 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. 12/6/2020 07:51:07 PM John Long Owner PAID INVOICE #: NCS‐01203‐2021 PERMIT #: NCS‐01203 AMOUNT: $550 PAYMENT METHOD: e‐check DATE: 12/8/2020 Chester Cobb