NCS00914_2022Permit_Initial

2022
Permit and Registration
Albemarle Septic Service
is hereby issued a Septage Management Firm Permit,
tszArr of
Permit Number NCS-00914
0
o and registered as a e:le D
` 7
NORTH CAROLINA
a= Septage Management Firm Department ofEnvironmental Quality
E#f QIIAM
NORTH CAROLINA (PUMPER)
Environmental Quality
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:
Elizabeth City WWTP, Elizabeth City NC
Town of Ahoskie, Ahoskie NC
3. Septage Detention or Treatment Facility, SDTF-15-02
4. Septage Land Application Site, SLAS-15-02
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. D; ;t 11 d b
igi a y signe y
Wm Perry Sugg
Date: 2022.10.02
20:32:06-04'00'
Perry Sugg, Environmental Compliance Branch Head

APPLICATION FOR PERM
IT TO OPERATE A SEPTA+GE MANAGEMENT FIRM
DIVISION OF WASTE MANA CEMENT - SOLD WASTE SECTION -1646 MAIL SERVICE CENTER. RALEIGH, NC 27699-1646
(9.J Firm name: ahe"Finn name" must be exa as it is shown on
your vehide(s).
Street address of office:
City:
state:
Mailing address (if different):
City:
State: ,dip:
Phone: � --
Pax:
E-Mail: .171A <, ,-1. /--, n- _. a _
County: r va L ~vim
Septage Management Firm permit number: NCS # ._Q491 [I
(2.) Firm ownees name: �-. L .r+ry � _
Mailing address (if dlffer�nt):
City: ! State:
--_--- Zip: Phone:, 9g(pQ
Fax:
(3.) Firm operator's name:
Firm operator's titie:K
Mailing address (i# different):
City: State:
._� Zip:
Phone: f
Fax:
() Type(s) of septage pumped: Write in the number of ila in Zoiz (Example: Domestic: 50,0vU0).
Domestic ! Portable Toilet Waste , Grease [Restaurant) t Treatment Plant lndustriaVCommercia(
(S.) N.C. Counties of
(6.) Total Number of Pumper
Number used for. DomA
Vehicle Information:
License Tac #
L —IV.t O!G Oy;
(List each county you do business in)
Vehicles Operated:
tic Septage:-- Grease (restaurant): -jel,
Portable Toilet Waste: - v
additional paper I needed)
Vehicle Identification #
T
CA-&k,mK—
TION CONTINUED ON PAGE
PAGE 3

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE
(CONTINUED FROM PAGE 9) MANAGEMENT FIRM
(7.) Septage Disposal Method: (check one)
a) Approved wastewater tr atment plant: yes no. If yes, submit Wastewater Treatment Authorization
for each plant, as indica ed in Subparagrap .0833 e 4 of the°n
Setae
Septage Management Rules.
b) Septage Land Applicati n Site (SLAS) Permit Nubbers: (use additional sheets if needed)
SLAS#: /tea. opiration Date: J%� SLAS#:
Expiration Date:
c) Septage Detention or TrLtment Facility (SD F) Permit Numbers
SDTF#: !� Elpimtlon Date: lose additional sheets if needed)
SDTF#: __ Expiration Date:
(8.) Septage Management Firm Operator Training Completed:
Date: Location:
Training Sp - nsored or Pro ided by: U Hours: -Y—
(9.) Septage Land I' App ication Site Operator Training Completed.
Date: zLocation: Training Sponsored or Provided by. Hours: _
(10) Registration type requested: Cf,iECK ON
Registered Portable Sanitation Firm:
Registered Septage Management Firm:
Registered Portable Sanita1on and Septage Management Firm.
Certification Statement
I certify that the information and r�resentations in this application for a permit are true, complete, and accurate to
the best of my knowledge and beliff. I am aware that a permit may be suspended or revoked upon a finding that its
issuance was based upon incorreQt or inadequate information that materially affected the decision to issue the
Permit and that there are criminal Ienalties for knowingly making a false statement, representation, or certification.
1a- io a r
I:VinatY(Signature of companyofFcialrequired) Date
le 99
Print Name
Other Comments:
SISolid_Waste:/CLAISEPTAGEIFORMS12016
oumtk
Tide

I�IT[ SEPTAGE MANAGEMENT FIRM.
Recertification of Pumper Vehicle(s)
Septage Firm Permit #: NCS-
Number of Pumper Vehicles:
CERTIFICATION:
"I certify, under penalty of law, that the pumper vehicle or vehicles listed in the
submitted permit application meet the requirements for safe and sanitary
transportation of septage as required by15A NCAC 13B .0844 (a) and vehicle
lettering as required by 15A NCAC 13B .0844 (b). I also certify that a log is
maintained of each septage pumping event as required by 15A NCAC 13B .0839
(a). I am aware that there are significant penalties for false certification including
the possibility of fine and imprisonment."
� e /
gna (Signature of company official required)
Print me
Date
rile
l,f),Yzx�-
S:1Solld_WastelcialseptagelformslPumper Vehicles Cetiflcation.doc

AUTHORIZATION TO DISCHARGE SEPTAGE TO A WASTEWATER TREATMENT FACILITY
North Carolina Department of Environmental Quality
Division of Waste Management - Solid Waste Section
1646 Mail Service Center, Raleigh, NC 27699-1646
Fee assessments and waste determinations will be required at the discretion of the wastewater
treatment facility. The facility has the ultimate prerogative to deny discharges of any wastes to the
incoming wastewater stream.
►Yfw {.JQ wa, -�6q (Plant Operator in Responsible Charge (ORC), ORC icense umber, Name of Plant) Awf
l t� ,!r___ a 7go4
/ ��// (Address) QJej ., ( ° �� y " gv
�P`-S 33 �� �6 do hereby authorize /rd ,
(Phone Number)
(Owner/Operator of Septage anagement Firm)
of
E- Ckl I C_ _ NCS # 00
(Se tage Management Firm Name and NCS number)
to dispose of: domestic septage J portable toilet waste X
grease septage (grease trap pumpings) _4 commercial/industrial septage from
(County o�therGEeograp�hicd�))
at the above named wastewater treatment facility. Septage shall be discharged at:
C ®2 7
(Location)
between the hours of 07cxs
Reintroducing partially treated liquid into a grease trap is acceptable Yes No
This authorization shall be valid until eice . �},t?�
(Usually December 31, Year)
Signed _ Date_ IL �O' I
(Facility Operator)
Sub ri ed and affi red before me this _ day of 20
My Commission expires: 1 I - 6 2025
(NM'�'_
ota Public) „
(cFlca`
Note: Falsification of this document by the septage management frm shall lead to permit �qo B
S:/Solid_Waste/CLA/SEPTAGE/FORMS/2018 Firm Application/WWTP Authorization Form 2018 N
`` 14011 11uNil,1,.

AUTHORIZATION TO DISCHARGE SEPTAGE TO A WASTEWATER TREATMENT FACILITY
North Carolina Department of Environmental Quality
Division of Waste Management - Solid Waste Section
1646 Mail Service Center, Raleigh, NC 27699-1646
Fee assessments and waste determinations will be required at the discretion of the wastewater
treatment facility. The facility has the ultimate prerogative to deny discharges of any wastes to the
incoming wastewater stream.
N]
(Plant Operator
Clyd D� o at
Charge (ORC), ORC License Number, Name of Plant)
0
- (A cress)
do hereby authorize1' \t s (Phone Number)
(Owner/Operator of eptage Management Firm)
of �b� Qr�C L C erv~\ C. C)
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage V-11
4, portable toilet waste V/
grease septage (grease trap pumpings) _ commercialAndustrial septage
'� N from
4M.,
(Countyorother Geographic Area) nOfat the above named wastewater treatment facility. Septage shall be discharged at: rT
�+ rn nano' e Levorr- NNW � P
� �� �''� S��►on a ue� ��
between the hours of , (Location)
Reintroducing partially treated liquid into a grease trap is acceptable y YeS
No
This authorization shall be valid until 3
(Usually December 31, Year)
Signed,
(Facility Operator)
Date
bscribed and affirmed before me this �,"
day of c4ob& 20 .Z
(Notary Public) M pires:
' NaTAf?
IulssloN (OFFICIAL SEAL)
S EXPIRES
$ V
Note: Falsification of this document by the septage manag`' S:/Solid Waste/cLA/sEPTAGE/FDpermit Firm Application/wWTP Authari,flli�.. c . �\ t0 revocation.

PAID
FIRM NAME: Albemarle Septic Service
PERMIT #: NCS-00914
AMOUNT: $800
PAID BY: Check
DATE: 12/14/2021
Adam Ulishney