NCS00790_2022Permit_Initial

2022
Permit and Registration
Shamrock Environmental Corporation

is hereby issued a Septage Management Firm Permit,
Permit Number NCS-00790
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. First Piedmont Waste Solutions Landfill, Ringgold VA
2. T.Z. Osbourne Water Reclamation Facility, Greensboro NC 3. Septage Detention or Treatment Facility, SDTF-41-03
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. 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
Shamrock Environmental Corporation
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-00790
Enter the five digits following the NCS #
City
Browns Summit
State / Province / Region
NC
Postal / Zip Code
27214
Country
United States
Street Address
6106 Corporate Park Dr
Address Line 2
Guilford
Yes No
8008811098 3363751801
[e-mail]
Owner Info
Shamrock Environmental Corporation
Yes No
3363751989 3363751801
Operator Info
Mike Dulin President
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*
3363751989 3363751801
Type and amount of septage pumped in the last 12 months
0
0
0
0
77,188
North Carolina counties of operation
All Counties
Vehicle Info
Yes No
11/29/2021
HSE Director
Add vehicles individually Upload List
Other LR-5183 1XPFDR9XXSN377409 3,500
Other LT-3226 1NP5LR0X0WN483637 3,500
Other LR-5175 1NP5LU0X83D803680 3,500
Other ND-4298 2M2N179Y3HC008033 3,500
Other ND-4297 1XPGDB9X84D827451 3,500
Approved wastewater treatment plant*
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*
Date*Hours *
Location *
Training Sponsored or Provided by*
Date Hours
Location
Training Sponsored or Provided by
Select one*
Other AH-78473 5HTNA422095E23572 6,000
Other AH-78474 1PMA14228B1037913 6,000
Other AH-82792 1A9114123Y1005065 6,000
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Yes No
Yes No
Yes No
SDTF-4103 8/31/2023
Yes No
Septage Management Firm Operator Training Completed
10/19/2021 4
Not Listed
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
Comments or notes
Signature
Date
Print Name*Title*
Septage managed at Co owned/operated SDTF.
Paid: Conf #21112980378438
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.
11/29/2021
07:44:24 PM
Jim Hollingsworth HSE Director
PAID
FIRM NAME: Shamrock Environmental Corporation
PERMIT #: NCS-00790
AMOUNT: $800
PAID BY: E-Check
DATE: 12/2/2021

Adam Ulishney