NCS01273_2022Permit_Initial

2022
Permit and Registration
Wrightsville Beach Marina

is hereby issued a Septage Management Firm Permit,
Permit Number NCS-01273
and registered as a Septage Management Firm
(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 authorized to discharge septage only at the locations(s) listed below: 1. Town of Wrightsville Beach Sewer, Wrightsville 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, 2022.

__________________________________________________ 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 oce*
County*
Mailing address same as street address of oce?*
Mailing Address*
Phone*Fax
Email*
Firm owner's name*
Mailing address same as street address of oce?*
Phone*Fax
Firm Info
Wrightsville Beach Marina and Transient Docks LLC
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-01273
Enter the five digits following the NCS #
City
Wrightsville Beach
State / Province / Region
NC
Postal / Zip Code
28480
Country
United States
Street Address
6 Marina St
Address Line 2
New Hanover
Yes No
City
Wrigthsville Beach
State / Province / Region
North Carolina
Postal / Zip Code
28480
Country
United States
Street Address
PO Box 1215
Address Line 2
9102566666
[e-mail]
Owner Info
Wrightsville Yacht Club Inc
Yes No
9102566666
Firm operator's name*Firm operator's title
Mailing address same as street address of oce?*
Mailing address*
Phone*Fax
Amount in gallons*
Domestic
Portable Toilet Waste
Grease (Restaurant)
Treatment Plant
Industrial/Commercial
List each county you plan to do business in:*
Do you plan to operate pumper vehicles?*
Approved wastewater treatment plant*
Septage Land Application Sites (SLAS)*
Septage Detention or Treatment Facility (SDTF)*
Operator Info
Samuel Clary Dockmaster
Yes No
City
Wrightsville Beach
State / Province / Region
NC
Postal / Zip Code
28480
Country
United States
Street Address
PO Box 1215
Address Line 2
9106162806
Type and amount of septage pumped in the last 12 months
0
300
0
0
0
North Carolina counties of operation
New Hanover
Vehicle Info
Yes No
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Yes No
Yes No
Yes No
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
Signature
Date
Print Name*Title*
Yes No
Pumped into Sewer
Septage Management Firm Operator Training Completed
4/3/2021 4
Online
NC DEQ - New Operator Training
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
Certication 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.
10/29/2021
09:59:03 AM
Samuel Clary Dockmaster
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 (http://mailto:
[e-mail])(919-707-8285) or Chester Cobb (http://mail to:[e-mail])(919-707-8283).
Firm name *
Septage Management Firm permit number (NCS #)*
Street address of oce *
County *
Mailing address same as street address of oce?*
Firm Info
Wrightsville Beach Marina and Transient Docks LLC
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-01273
Enter the five digits following the NCS #
City
Wrightsville Beach
State / Province / Region
NC
Postal / Zip Code
28480
Country
United States
Street Address
6 Marina St
Address Line 2
New Hanover
Yes No
Mailing Address*
Phone *Fax
Email *
Firm owner's name*
Mailing address same as street address of oce?*
Phone *Fax
Firm operator's name *Firm operator's title
Mailing address same as street address of oce?*
City
Wrigthsville Beach
State / Province / Region
North Carolina
Postal / Zip Code
28480
Country
United States
Street Address
PO Box 1215
Address Line 2
9102566666
[e-mail]
Owner Info
Wrightsville Yacht Club Inc
Yes No
9102566666
Operator Info
Samuel Clary Dockmaster
Yes No
Mailing address*
Phone *Fax
Amount in gallons*
Domestic
Portable Toilet Waste
Grease (Restaurant)
Treatment Plant
Industrial/Commercial
List each county you plan to do business in:*
City
Wrightsville Beach
State / Province / Region
NC
Postal / Zip Code
28480
Country
United States
Street Address
PO Box 1215
Address Line 2
9106162806
Type and amount of septage pumped in the last 12 months
0
300
0
0
0
North Carolina counties of operation
New Hanover
Vehicle Info
Do you plan to operate pumper vehicles?*
Approved wastewater treatment plant*
Septage Land Application Sites (SLAS)*
Septage Detention or Treatment Facility (SDTF)*
Other disposal method*
Description*Authorization
+ Add another Other Disposal
Date *Hours*
Location *
Training Sponsored or Provided by *
Date Hours
Yes No
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
Pumped into Sewer Upload
Septage Management Firm Operator Training Completed
4/3/2021 4
Online
NC DEQ - New Operator Training
Septage Land Application Site Operator Training Completed
0
Location
Training Sponsored or Provided by
Select one *
Comments or notes
Signature*
Date
Print Name *Title*
Submit Save as Draft
Registration Type
Registered Portable Sanitation Firm
Registered Septage Management Firm
Registered Portable Sanitation and Septage Management Firm
Comments and Notes
Certication 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.
×
10/29/2021
09:59:03 AM
Samuel Clary Dockmaster
PAID
FIRM NAME: Wrightsville Beach Marina
PERMIT #: NCS-01273
AMOUNT: $550
PAID BY: E-Check
DATE: 9/30/2021

Adam Ulishney