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Home My WebLink AboutNCS01248_2022Permit_Initial2022 Permit and Registration New Life II Rent-A-Jon & Jane is hereby issued a Septage Management Firm Permit, Permit Number NCS-01248 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. Archie Elledge WWTP, Winston-Salem 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 aSeptage 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 New Life II Rent a Jon & Jane The "Firm name" must be exactly as it is shown on your vehicle(s). NCS-01248 Enter the five digits following the NCS # City Winston Salem State / Province / Region NC Postal / Zip Code 27105 Country United States Street Address 704 Edmon Ct Address Line 2 Forsyth Yes No 336-699-3868 theresa0353@att.net Owner Info Timothy Lawson Yes No 336-699-3868 Operator Info Theresa Lawson 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* 336-462-0353 Type and amount of septage pumped in the last 12 months 850,000 175,000 0 0 0 North Carolina counties of operation Forsyth, Stokes, Surry, Yadkin, Davie, Davidson, Guilford, Rockingham Vehicle Info Yes No 12/13/2021 President Add vehicles individually Upload List Domestic Septage YA146104 2NPLH27X77M687805 2,500 Domestic Septage YA147841 1GDT7H4JGWJ508515 3,000 Domestic Septage YA117313 1FVACWDC76HX18212 2,500 Domestic Septage YA137349 1HTSCPLM8PH485753 1,800 Portable Toilet Waste KC2262 3C7WRLBJ8LG121434 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)* Other disposal method* Date*Hours * Location * Training Sponsored or Provided by* Date Hours Location Training Sponsored or Provided by Portable Toilet Waste HA7534 3C6LR5ATOGG314494 250 Portable Toilet Waste KT7265 1GDE5C1938F412262 500 Portable Toilet Waste JK1271 3C7WRLAJ8JG154349 500 Septage Disposal Method For each method, indicate whether you plan to use it by checking yes or no. Yes No Archie Elledge Wastewater Facility 12/31/2022 Scan_2021121…469.36… Scan_20211213 (2).pdf 562.7KB Yes No Yes No Yes No Septage Management Firm Operator Training Completed 3/30/2021 6 Hickory Metro Convention Center NC Septic Tank Association Septage Land Application Site Operator Training Completed 0 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 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. 12/13/2021 04:07:21 AM Theresa Lawson President PAID FIRM NAME: New Life II rent a jon and jane PERMIT #: NCS-01248 AMOUNT: $800 PAID BY: E-Card DATE: 12/15/2021 Adam Ulishney