NCS00398_2020Permit_application_memo

Memo:
Check for 2020 firm permit fee received with incorrect information was
returned to firm 1/2/2020.
No permit fee received for 2020.
JRB 8/11/2021

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
Brooks Septic Tank & Port a John service
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-00398
Enter the five digits following the NCS #
City
Ridgeway
State / Province / Region
Va
Postal / Zip Code
24148
Country
HENRY
Street Address
246 Green Leaf Cr
Address Line 2
Rockingham
Yes No
2769563510
[e-mail]
Owner Info
Larry Brooks
Yes No
2797326402
Operator Info
Larry Brooks owner
Yes No
2767326402
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.
Type and amount of septage pumped in the last 12 months
10,000
0
20,000
0
0
North Carolina counties of operation
Rockingham
Vehicle Info
Yes No
12/28/2019
owner
Add vehicles
individually
Upload List
Grease (restaurant)TK155016 2NKMD7X0YM863463 2,200
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Yes No
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**
Comments or notes
Signature
UPPER SMITH RIVER WASTE WATER
TREATMENT PLANT
12/31/2021
Yes No
Yes No
Yes No
Septage Management Firm Operator Training Completed
11/5/2019 4
GREENSBORO
NC Septic Tank Association
Septage Land Application Site Operator Training Completed
11/5/2019
Registration Type
Registered Portable Sanitation Firm
Registered Septage Management Firm
Registered Portable Sanitation and Septage Management Firm
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.
Date
Print Name**Title**
12/28/2019
07:35:08 PM
LARRY BROOKS OWNER