NCS00168_2022Permit_Initial

2022
Permit and Registration
A Sani-Can

is hereby issued a Septage Management Firm Permit,
Permit Number NCS-00168
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. Septage Detention or Treatment Facility, SDTF-41-06 2. T Z Osborne WRF, Mcleansville 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.

__________________________________________________ Perry Sugg, 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
A Sani-Can
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-00168
Enter the five digits following the NCS #
City
Greensboro
State / Province / Region
NC
Postal / Zip Code
27405
Country
United States
Street Address
2316 Joe Brown Drive
Address Line 2
Guilford
Yes No
City
Denver
State / Province / Region
NC
Postal / Zip Code
28037
Country
United States
Street Address
8151 Webbs Road
Address Line 2
7044835641 7044838481
[e-mail]
Owner Info
Gary & Virginia Dellinger
Yes No
7044835641 7044838481
Firm operator's name*Firm operator's title
Mailing address same as street address of oce?*
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*
Operator Info
Gary Dellinger Secretary
Yes No
7044835641 7044838481
Type and amount of septage pumped in the last 12 months
0
371,178
0
0
0
North Carolina counties of operation
Guilford, Davidson, Randolph, Forsyth, Stokes, Moore, Rockingham, Chatham,
Orange, Durham, Wake, Alamance, Franklin
Vehicle Info
Yes No
10/29/2021
Treasurer
Add vehicles individually Upload List
Upload vehicle list*
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)*
Other disposal method*
Description*Authorization
Date*Hours *
Location *
Training Sponsored or Provided by*
Date Hours
Location
Training Sponsored or Provided by
You can upload a file with a list of vehicles to be used. Please be sure to include the following information for each vehicle on your upload: Usage, License Tag #, Vehicle
Identification #, and Tank Capacity.
2022 Greensboro Trucks.pdf 38.83KB
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Yes No
ORC-TZ Osborne Water Reclamation 12/31/2022
Yes No
Yes No
Yes No
Onsite into the county
Septage Management Firm Operator Training Completed
3/29/2021 12
Hickory, NC
NC Septic Tank Association
Septage Land Application Site Operator Training Completed
3/29/2021 6
Hickory, NC
NC Septic Tank Association
Select one*
Comments or notes
Signature
Date
Print Name*Title*
Registration Type
Registered Portable Sanitation Firm
Registered Septage Management Firm
Registered Portable Sanitation and Septage Management Firm
Comments and Notes
I have not received ORC-TZ Osborne Water Reclamation authorization to
discharge paper yet; as soon a I receive it I will mail that in.
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
04:30:00 PM
Neeley Robinson Treasurer
PAID
FIRM NAME: A Sani-Can
PERMIT #: NCS-00168
AMOUNT: $800
PAID BY: E-Card
DATE: 11/2/2021

Adam Ulishney