NCS01203_2022Permit_Initial

2022
Permit and Registration
Klean Latrine Septic Pumping
is hereby issued a Septage Management Firm Permit,
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Permit Number NCS-01203
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o and registered as a e:-e DE
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` a= Septage Management Firm Department ofEnvironmental Quality
44 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:
1. West Brunswick Regional WWTF, Supply NC
2. Septage Land Application Site, SLAS-24-10
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.
Digitally signed by
Wm Perry Sugg
Date: 2022.10.02
20:34:26-04'00'
Perry Sugg, Environmental Compliance Branch Head

For questions regarding this form or the online application process, please contact Jeffrey Bullard (919-707-8285) or Chester Cobb (919-707-
8283).
Firm Info
Firm name*
Klean Latrine Septic Pumping
The "Firm name" must be exactly as it is shown on your vehicle(s).
Septage Management Firm permit number (NCS #)
NCS-01203
Enter the five digits following the NCS #
Street address of office*
Street Address
PO Box 563
Address Line 2
City
State / Province / Region
Shallotte
North Carolina
Postal / Zip Code
Country
28459
United States
County*
Columbus
Mailing address same as street address of office?*
• Yes No
Phone* Fax
910-620-5645
Email*
[e-mail]
Owner Info
Firm owner's name*
JOHN LONG
Mailing address same as street address of office?*
• Yes No
Phone* Fax
910-620-5645
Operator Info
Firm operator's name* Firm operator's title
Klean Latrine Septic Pumping Owner
Mailing address same as street address of office?*
0 Yes No

Phone* Fax
910-620-5645
Type and amount of septage pumped in the last 12 months
Amount in gallons*
Domestic 626,000
Portable Toilet Waste 0
Grease (Restaurant) 0
Treatment Plant 0
Industrial/Commercial 0
North Carolina counties of operation}
List each county you plan to do business in: *
Brunswick, Columbus, New Hanover, Pender
Vehicle Info^j
Do you plan to operate pumper vehicles?*
• Yes No
"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*
12/28/2021
Title*
Owner
Choose how to add vehicle descriptions*
• Add vehicles individually Upload List
Pumper Vehicles
Usage* License Tag #* Vehicle Identification #* Tank Capacity*
Domestic Septage YA103825 1HTSDAANlYH276913 2,000
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Approved wastewater treatment plant*
0 Yes No

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*
West Brunswck Regional Wastewater
Treatment Facility
Septage Land Application Sites (SLAS)*
• Yes No
Expiration Date* Authorization
12/31/2022 WWTP 380.02...
Authorization
for Klean
Latrine.pdf
If you are not the permit holder for the septage land application site, you must have a signed land application authorization form for each site.
SLAS #*
SLAS-24-10
Expiration Date*
12/31/2021
Septage Detention or Treatment Facility (SDTF)*
Yes • No
Other disposal method*
Yes • No
Authorization
Septage Management Firm Operator Training Completed
Date* Hours*
4/7/2021 4
Location*
Shallotte
Training Sponsored or Provided by*
NC Septic Tank Association
Septage Land Application Site Operator Training Completed^
Date Hours
4/8/2021 3
Location
Shallotte
Training Sponsored or Provided by
NC Septic Tank Association
Registration Type^

Select one*
Registered Portable Sanitation Firm
• Registered Septage Management Firm
Registered Portable Sanitation and Septage Management Firm
Comments and Notes
Comments or notes
Certification 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
12/28/2021
07:59:39 PM
Print Name* Title*
John Long Owner

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.
1, Tim Webb, # 21200, West Brunswick Regional Wastewater Treatment Facility
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
235 Grey Water Road, Supply, NC 28462
(Address)
[phone] do hereby authorize John Long
(Phone Number) (Owner/Operator of septage Management Firm)
of _ Klean Latrine Septic Pumping NCS # 01203
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage X portable toilet waste
grease septage (grease trap pumpings) commercial/industrial septage , from
Brunswick County
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
West Brunswick Regional Wastewater Treatment Facility, 235 Grey Water Road, Supply, NC
(Location)
between the hours of Monday -Friday 8 a.m. - 6 p.m.; Weekends & Holidays 9 a.m. - 5 p.m.
Reintroducing partially treated liquid into a grease trap is acceptable Yes X No
This authorization shall be valid until _ December 3.1, 2022
(Usually December 31, Year)
Signed Date/� -
(Facility Operator)
Tim Webb personally known to me
Subscribed and affirmed before me this _ l _ day of bkU_ Y A rf', 20 a
My Commission expires: q a 1e
(Notary Public)
LAURf ILLER
Notary Pubi ii
Brunswick County
ism My C% mis�ss! n Expires Nizrr
Note: Falsification of this document by the septage management firm shall lead to permit revocation.
S:/Solid_Waste/CLA/SEPTAGE/FORMS/2018 Firm Application/WWTP Authorization Form 2018

PAID
FIRM NAME: Klean Latrine Septic Pumping
PERMIT #: NCS-01203
AMOUNT: $550
PAID BY: E-Check
DATE: 12/17/2021
Adam Ulishney