NCS01249_Non-Pumper Application for a Permit to Operate a

State of North Carolina
Environmental Quality
Waste Management
Non-Pumper Application for a Permit
to Operate a Septage Management
Facility
NON-PUMPER - $200 FEE PER FACILITY
Facility Name:**
Street address:**
Street address - City:**
Street address - State:**
Street address - Zip:**
Street address - County:**
Mailing address same as Street
address:**
Facility Owner's Name:**
Mailing address:**
Mailing address - City:**
Mailing address - State:**
Mailing address - Zip:**
Phone:**
Email:**
Facility Operator's Name:**
Mailing address:**
Mailing address - City:**
Mailing address - State:**
Mailing address - Zip:**
Phone:**
Email:
Type(s) of septage managed:**
Facility Types:
Provide the permit numbers for all that are applicable.
Facility
Richard Todd Black
3458 Zion Hill Road
Cherryville
NC
28021
Lincoln
Yes No
Owner
Richard Todd Black
3458 Zion Hill Road
Cherryville
NC
28021
704-435-0938
[e-mail]
Operator
Richard Todd Black
3458 Zion Hill Road
Cherryville
NC
28021
7044350938
[e-mail]
Septage
(check all that apply)
Domestic Portable Toilet Waste Grease (restaurant)
Treatment Plant Industrial/Commercial
a. Septage Land Application Site
b. Boat Pump-Out Storage
c. Septage Storage Tanks
d. Septage Treatment
e. Grease Treatment
Septage Management firms using facility:
Provide name and permit number of all permitted septage management firms using facility.
Permit Number Firm Name
11
22
33
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:
Date:
Title:
Email:**
SDTF-55-03
SDTF-55-03 R.V. Campers Only
Certification
(signature of company official required)
11/17/2020
Owner
[e-mail]
PayPoint
Payment Receipt
Application: Solid Waste Credit
Merchant: NDENR-Solid Waste Credit
Merchant City/State: Raleigh, North Carolina
Merchant Location Code: 00001
Payment Status: Settled
Result Message: Payment completed and settled successfully.
Confirmation Number: 20111714028779
Payment Date: 11/17/2020
Posting Date: 11/17/2020
Billing Information: Richard Todd BLACK 3458 Zion Hill Road Cherryville, NC 28021 7044350938 [e-mail]
Payment Amount: 200.00 USD
Card Type:
Account #:
Authorization Code: 128074
Method: Not Present
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Reference Information: NCS-01249-2021,28021,Scenic Ridge Country Campground,3458 Zion Hill Rd,Cherryville,NC,NCS-01249,$200.00
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https :// admin. thepayplace.com/epayadmin/paymentreceipt.aspx 11/18/2020