NCS01162_2022Permit_Initial

2022
Permit and Registration
A & D Environmental Service, Inc.

is hereby issued a Septage Management Firm Permit,
Permit Number NCS-01162
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. Old Mason Farm Plant, Chapel Hill NC
2. Eastside WWTP, High Point NC 3. Septage Detention or Treatment Facility, SDTF-34-02
4. Great Oak Landfill, Randleman 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?*
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?*
Firm Info
A&D Environmental Service Inc.
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-01162
Enter the five digits following the NCS #
City
Archdale
State / Province / Region
NC
Postal / Zip Code
27263
Country
United States
Street Address
2718 Uwharrie Road
Address Line 2
Randolph
Yes No
336-434-7750 336-417-5544
[e-mail]
Owner Info
A&D Holding, Inc.
Yes No
336-434-7750 336-417-5544
Operator Info
Travis Clapp Resource Manager
Yes No
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?*
"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 .0835(a) and vehicle lettering as required by 15A NCAC .0835(b).
Furthermore, I also certify that a log is maintained of each septage pumping event as required by 15A NCAC 13B .0836(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*
336-434-7750 336-417-5544
Type and amount of septage pumped in the last 12 months
0
0
1,025
0
146,200
North Carolina counties of operation
All Counties
Vehicle Info
Yes No
12/7/2021
Fleet Manager
Add vehicles individually Upload List
Grease (restaurant)NL6403 1NPTL40X9FD262005 3,500
Grease (restaurant)MX6642 1NPTL40X4ED218850 3,500
Grease (restaurant)AM42088 10BGS6217SF0A5175 3,500
Grease (restaurant)AM42080 1HLK1B7B0L9D40439 3,500
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.
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)*
If you are not the permit holder for the septage detention/treatment facility, you must have a signed detention/treatment authorization form for
each site.
SDTF #*Expiration Date *Authorization
Other disposal method*
Description*Authorization
Date*Hours *
Location *
Training Sponsored or Provided by*
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Yes No
Piedmont Triad Area; Eastside WWTP
Septage Receiving Station
12/31/2021 AD.WWTP
Doc.pdf
68.8KB
Orange And Surrounding Counties 12/31/2021 AD WWTP
II.pdf
84.37KB
Yes No
Yes No
SDTF-34-02 12/31/2021 AD.SDTF.pdf 57.46KB
Yes No
Solidified Material sent to Landfill12 Waste
Management, Great Oak Landfill AD.SMTL.pdf 260.28…
Septage Management Firm Operator Training Completed
2/17/2021 4
Online
NC Pumper Group & NC Portable Toilet Group
Date Hours
Location
Training Sponsored or Provided by
Select one*
Comments or notes
Signature
Date
Print Name*Title*
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.
12/6/2021
11:32:57 AM
Arthur L Campbell Fleet Manager
PAID
FIRM NAME: A&D Environmental Services Inc.
PERMIT #: NCS-01162
AMOUNT: $800
PAID BY: E-Card
DATE: 12/10/2021

Adam Ulishney