NCS01249_2022Permit_Initial

2022
Permit and Registration
Scenic Ridge Country Campground

is hereby issued a Septage Management Firm Permit,
Permit Number NCS-01249
and registered as a Septage Management Firm
(NON-PUMPER)
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 only authorized to operate Septage Management Facilities listed below: 1. Septage Detention or Treatment Facility, SDTF-55-03
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. Also, this permit does not entitle the permit holder to operate a pumper vehicle for the transportation of septage. 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, 2022.

__________________________________________________ Adam Ulishney, Environmental Compliance Branch Head
State of North Carolina
Environmental Quality
Waste Management
Non-Pumper Application for a Permitto Operate a Septage ManagementFacility
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
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
704-435-0938
[e-mail]
Septage
(check all that apply)
Domestic Portable Toilet Waste Grease (restaurant)
Treatment Plant Industrial/Commercial
Facility Types:
Provide the permit numbers for all that are applicable.
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
1
2
3
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
Certication
(signature of company official required)
10/25/2021
Owner
[e-mail]
PAID
FIRM NAME: Scenic Ridge Country Campground
PERMIT #: NCS-01249
AMOUNT: $200
PAID BY: E-Card
DATE: 10/27/2020

Adam Ulishney