NCS00711_2021Permit_Initial

2021
Permit and Registration

P. D. Quik
is hereby issued a Septage Management Firm Permit, Permit Number NCS-00711
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. Mount Airy WWTP, Mount Airy 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
P.D.Quik
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-00711
Enter the five digits following the NCS #
City
Mount Airy
State / Province / Region
NC
Postal / Zip Code
27030
Country
US
Street Address
133 Mason Rd
Address Line 2
Surry
Yes No
336 786-2286 -----
[e-mail]
Owner Info
Donald Goins
Yes No
336 786-2286 ------------
Operator Info
Donald Goins President
Yes No
336 786-2286 -------
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
500,000
0
50,000
450,000
50,000
North Carolina counties of operation
Surry Wilkes Yadkin Stokes Alleghany
Vehicle Info
Yes No
10/24/2020
President
Add vehicles
individually
Upload List
Grease (restaurant)YA 47796 1FUY3ECB5MH386354 2,100
Domestic Septage YA12013 1XPd68X2SN362051 4,000
Domestic Septage KH6710 JNALC20H3SGN50246 2,000
Domestic Septage YA128120 NCS9210011111111 3,000
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or 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**
Comments or notes
Yes No
Mt Airy 12/31/2021
Yes No
Yes No
Yes No
Septage Management Firm Operator Training Completed
1/30/2020 6
Hickory N.C.
NC Septic Tank Association
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
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
Signature
Date
Print Name**Title**
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.
10/24/2020
11:08:59 AM
Donald Goins President
Pay Point
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: 20102410383003
Payment Date: 10/24/2020
Posting Date: 10/24/2020
Billing Information: P.O. Qiuk Inc 133 Mason Rd 133 Mason Rd Mount Airy, NC 27030 3367862286 [e-mail]
Payment Amount: 800.00 USO
Method: Not Present
Reference Information: NCS-00711-2021,27030,P D Quik,133 Mason Road,Mt Airy,NC,NCS-00711,$800.00
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https://admin.thepayplace.com/epayadmin/paymentreceipt.aspx 10/26/2020