NCS01481_2022Permit_Initial

2022
Permit and Registration
Southern Port-A-John

is hereby issued a Septage Management Firm Permit,
Permit Number NCS-01481
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-82-04.
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
Southern Poort-A-John
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-01481
Enter the five digits following the NCS #
City
Garland
State / Province / Region
North Carolina
Postal / Zip Code
28441
Country
United States
Street Address
2597 lamb road
Address Line 2
Sampson
Yes No
910-592-8791
[e-mail]
Owner Info
Wayne Horne/Samuel Horne
Yes No
910-592-8791
Operator Info
Wayne Horne/Samuel Horne Owners
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*
910-592-8791
Type and amount of septage pumped in the last 12 months
0
65,400
0
0
0
North Carolina counties of operation
Sampson,Cumberland,Bladen,Pender,Dublin,Wayne,Johnston,Harnet
Vehicle Info
Yes No
12/14/2021
Owners
Add vehicles individually Upload List
Portable Toilet Waste JJ-2870 3c7wrtcj5hg587392 500
Portable Toilet Waste JY-8955 1gb3kycg1jf104725 500
Portable Toilet Waste JJ-2868 3d6wh4elxag125172 400
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
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*
Comments or notes
Yes No
Yes No
Yes No
SDTF-82-22 5/26/2022
Yes No
Septage Management Firm Operator Training Completed
12/4/2021 4
Raleigh,NC
NC Pumper Group & NC Portable Toilet Group
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.
Signature
Date
Print Name*Title*
12/14/2021
12:08:11 AM
Wayne Horne/Samuel Horne Owners
PAID
FIRM NAME: Southern Port a John
PERMIT #: NCS-01481
AMOUNT: $800
PAID BY: E-Card
DATE: 3/22/2022

PAID (late)
FIRM NAME: Southern Port a John
PERMIT #: NCS-01481
AMOUNT: $400
PAID BY: E-Card
DATE: 3/15/2022

Adam Ulishney