NCS00900_2021Permit_Initial

2021
Permit and Registration

Lake Gaston Campground
is hereby issued a Septage Management Firm Permit, Permit Number NCS-00900
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. Lake Gaston Campground On-Site Wastewater Disposal System
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?**
Mailing Address**
Phone**Fax
Firm Info
Lake Gaston RV Resort
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-00900
Enter the five digits following the NCS #
City
Littleton
State / Province / Region
NC
Postal / Zip Code
27850
Country
USA
Street Address
561 Fleming Dairy Road
Address Line 2
Warren
Yes No
252-586-1400
[e-mail]
Owner Info
MHC Lake Gaston LP
Yes No
City
Chicago
State / Province / Region
Illinois
Postal / Zip Code
60606
Country
United States
Street Address
2N Riverside Plaza
Address Line 2
Suite 800
312-279-1400 312-279-1710
Firm operator's name**Firm operator's title
Mailing address same as street address of office?**
Phone**Fax
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*
Operator Info
Gary Morgan Maintenance Supervisor
Yes No
252-586-4121
Type and amount of septage pumped in the last 12 months
0
194,550
0
0
0
North Carolina counties of operation
Warren County
Vehicle Info
Yes No
3/19/2021
Community Manager
Add vehicles
individually
Upload List
Approved wastewater treatment plant **
Septage Land Application Sites (SLAS)**
Septage Detention or Treatment Facility (SDTF)**
Other disposal method**
Description*Authorization
Date**Hours**
Location**
Training Sponsored or Provided by**
Date Hours
Location
Training Sponsored or Provided by
Select one**
Comments or notes
Portable Toilet Waste N/A Off Road Tractor 350
Portable Toilet Waste N/A Off Road Tractor 500
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Yes No
Yes No
Yes No
Yes No
On site in Lke Gaston Campground State Approved
Septic System
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
Registered Portable Sanitation Firm
Registered Septage Management Firm
Registered Portable Sanitation and Septage Management Firm
Comments and Notes
Certification Statement
Signature
Date
Print Name**Title**
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.
3/19/2021
01:37:02 AM
Jennifer Hamby Community Manager
PAID
INVOICE #: NCS‐00900‐2021 
PERMIT #: NCS‐00900 
AMOUNT: $800 
PAYMENT METHOD: e‐check 
DATE: 12/11/2020 

Chester Cobb