NCS00900_2022Permit_Initial

2022
Permit and Registration
Lake Gaston Campground

is hereby issued a Septage Management Firm Permit,
Permit Number NCS-00900
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. Lake Gaston Campground On-Site Wastewater Disposal System
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?*
Phone*Fax
Email*
Firm owner's name*
Mailing address same as street address of oce?*
Mailing Address*
Firm Info
Lake Gaston RV Resort
The "Firm name" must be exactly as it is shown on your vehicle(s).
NCS-00900
Enter the five digits following the NCS #
City
Littleton
State / Province / Region
NC
Postal / Zip Code
27850
Country
United States
Street Address
561 Fleming Dairy Rd
Address Line 2
Warren
Yes No
252-586-4121
[e-mail]
Owner Info
MHC Lake Gaston LP
Yes No
City
Chicago
State / Province / Region
IL
Postal / Zip Code
60606
Country
US
Street Address
2 N Riverside Plaza
Address Line 2
Suite 800
Phone*Fax
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*
Pumper Vehicles
312-279-1400
Operator Info
Gary Morgan Maintenance Supervisor
Yes No
252-586-4121
Type and amount of septage pumped in the last 12 months
0
123,685
0
0
0
North Carolina counties of operation
Warren
Vehicle Info
Yes No
12/9/2021
Community Manager
Add vehicles individually Upload List
Usage*License Tag #*Vehicle Identification #*Tank Capacity*
Approved wastewater treatment plant*
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
Select one*
Portable Toilet Waste N/A OFF ROAD TRACTOR 350
Portable Toilet Waste N/A OFF ROAD TRACTOR 500
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
On site in Lake Gaston Campground State Approved
Septic System
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
Comments or notes
Signature
Date
Print Name*Title*
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.
12/9/2021
12:38:07 PM
Jennifer Hamby Community Manager
PAID
FIRM NAME: Lake Gaston Campground
PERMIT #: NCS-00900
AMOUNT: $800
PAID BY: E-Check
DATE: 12/14/2021

Adam Ulishney