NCS01341_2022Permit_Initial

NORTH CAROLINA
Environmental Quality
2022
Permit and Registration
Shorties Pot O' Gold
is hereby issued a Septage Management Firm Permit,
Permit Number NCS-01341
and registered as a
Septage Management Firm
(PUMPER)
in the State of North Carolina.
,:����D E
PfORTH CAROLINA :;.�
Department of Environmental quality
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:
Warren County WWTP, Warren 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. Digitally signed by
Wm Perry Sugg
Date: 2022.10.02
20:46:37-04'00'
Perry Sugg, Environmental Compliance Branch Head

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
DIVISION OF WASTE MANAGEMENT - SOLID WASTE SECTION -1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646
(1.) Firm name: (The "Firm name" must be exactly as it is shown on your vehicle(s)).
5H-OR-7Ems ?e-T` D' 66L-C�
Street address of office: I N G, Ad I u.
City: I ► I 0 State:NC— Zip: '22 SS
Mailing address (if different): P o -A-Z, o )C t 04
City: l' State: /VC- Zip Z7 $So
Phone:�-�"�'tZ°-1 Fax: �g(,� ' Zoo (®
E-Mail: g<b g q ",.c,Q s !;;W
County:_kgcj- Septage Management Firm permit number: NCS # j9 I3
(2.) Firm owner's name:y 1t�2. C L.OrttG-
Mailing address (if different): ?073 o x 1 Li I
City: I r i -,krvi) State: Ne- Zip % KIi-D
Phone: 7--5 Z 57 Z 04 &S Fax: %52- Z a q 4
(3.) Firm operator's name: 919-rN1 t✓ OIL—> Firm operator's title:
Mailing address (if different):
City:
Phone:
State: Zi
Fax:
(4.) Type(s) of septage pumped: Write in the number of aallons numn d to last 12 months (Example: Domestic: 50,000).
Domestic Portable Toilet Waste Grease (Restaurant) Treatment Plant Industrial/Commercial
(5.) N.C. Counties of Operation: WK,9, nJ 44-Asi , ApT4+AyA PTh,)
tvA
(List each county you are authorized to do business in)
(6.) Total Number of Pumper Vehicles Operated: ©N J-
Number used for: Domestic Septage: 00 5P- Grease (restaurant):
Other: Portable Toilet Waste:
Vehicle Information: (use additional paper if needed)
License Tag #
Vehicle Identification #
Tank Capacity
1
2
3
4
5
APPLICATION CONTINUED ON PAGE 2
PAGE

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
(CONTINUED FROM PAGE 1)
(7.) Do you plan to operate pumper vehicles? (check one) X,i yes ( ) no.
If you checked yes above, you must attest to the following statement before a permit may be issued.
"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 are significant penalties for false certification including the
possibility of fine and imprisonment."
Do you attest to the statement above? ('�) yes ( ) no InitialDate 1 D Z 70Z
(8.) Septage Disposal Method: (check one)
a) Approved wastewater treatment plant: () yes ( ) no. If yes, submit Wastewater Treatment Authorization for each
plant, as indicated in Subparagraph .0834(c)(14) of the Septage Management Rules.
b) Septage Land Application Site (SLAS) Permit Numbers: (use additional sheets if needed)
SLAS#: Expiration Date: SLAS#: Expiration Date:
c) Septage Detention or Treatment Facility (SDTF) Permit Numbers: (use additional sheets if needed)
SDTF#: Expiration Date: ►Z�'iIISZZ SDTF#: Expiration Date: _
(9.) Septage Management Firm Operator Training Completed:
Date: A& 7-02► 2-202 Location: &)0QAt)F_,, Hours:
Training Sponsored or Provided by: A) M.-Li INS
(10.) Septage Land Application Site Operator Training Completed:
Date: Location:
Training Sponsored or Provided by:
(11.) Registration type requested: CHECK ONE
Registered Portable Sanitation Firm:
Registered Septage Management Firm:
Registered Portable Sanitation and Septage Management Firm:
Certification Statement
Hours:
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 (Signature of companyofficial red)
L4��3i&n_ E. L&)6
Other Comments:
Date
&yor�-P_
Title
PAGE 2
Rev. 04-26-2021

AUTHORIZATION TO DISCHARGE SEPTAGE TO A WASTEWATER
TREATMENT FACILITY
North Carolina Department of Environment and Natural Resources
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.
William R. Perkinson, ORC License Number 987831
(Plant Operator in Responsible Charge (ORC) and ORC License Number)
Warren County WWTP, 738 US HvJy 401 S.. PO BOX 281. Warrenton, NC 27589
(Address)
252-257-1776 do hereby authorize Daniel Long
(Phone Number) (Owner/Operator of Septage Management Firm)
of Shorties Pot of Gold NCS #01341
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage X portable toilet waste X
grease septage (grease trap pumpings) commercial/industrial Septage from
Warren. Vance. Granville and surrounding counties
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
Influent works _
(Location)
between the hours of 8:00 AM - 3:30 PM Mondav - Fridav
Reintroducing partially treated liquid into a grease trap is acceptable Yes X No
This authorization shall be valid until December 31, 2022
(Usually December 31, Year)
l•
Signed Date zd ',"Z%
(Facility O'perator)
Sworn to and subscribed before me this
(Notary Public)
dayofo
My Commission expires.
s �OSAgy
�y�
1 r
FICIAL SEAL)
-A
Note: Falsification of this document by the septage management firm shall lead to permit revocation. P'
♦♦
At
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S:/Solid_Waste/CLA/SEPTAGE/FORMS/2013 Firm Application/WWTP Authorization Form 2013 list �`'`,``%
INV

North Carolina Department of Environmental Quality
rr Division of Waste Management
Solid Waste Section INVOICE=
Division of Waste Management To: Daniel Long
Solid Waste Section Shorties Pot O' Gold
1646 Mail Service Center PO Box 1049
Raleigh, NC 27699-1646 Littleton, NC 27850
phone: [phone] fax: [phone]
email: [e-mail]
Septage-Annual:
Shorties Pot O' Gold (NCS-01341)
PO Box 1049
Littleton, NC 27850
Number of Trucks: 1
Payment Options:
Date: 09/20/2021
Invoice #: NCS-01341-2022
Description Amount Due
$550.00
Total Amount Due $550.00
Date Due 12/15/2021
E-check - Available online at http://go.ncdenr.gov/swpay
Requires bank account and routing information. You will need to use the zip code in the description box and the invoice number
shown on this invoice to access your account. If a zip code is not listed, use the code: 99999 along with the invoice number.
Credit Card - Available online at http://go.ncdenr.gov/swpay
Accepts MasterCard, Visa, and Discover cards. You will need to use the zip code in the description box and the invoice number
shown on this invoice to access your account. If a zip code is not listed, use the code: 99999 along with the invoice number.
["'Convenience Fee of 2.65% added to amount invoiced.]
Paper check - Make checks payable to N.C. Division of Waste Management, Solid Waste Section, include Permit Number and invoice number on
check. If you are paying by electronic transfer, include the invoice number with your electronic transfer. Please return a copy of
this invoice with your payment.
[G.S. 25-3-506: A $25.00 processing fee will be charged on all returned checks.]
Explanation of Invoice Amount is Based on Facility's Current Permit Status:
Pursuant to North Carolina General Statute 130A-291.1 you are required to pay fee(s) based on your solid waste management activities. The fee(s)
shall be used to support the septage management program.
Solid Waste Contacts:
Billing process:
Alby Alexander [phone]
Regulations and Technical Assistance:
Adam Ulishney [phone] Septage Management Firms, Land Application Sites, Detention Facilities
More information available on the web:
North Carolina Department of Environmental Quality (DEQ) - http://deq.nc.gov
North Carolina Solid Waste Program - http://deq.nc.govlabout/divisions/waste-managemenVsolid-waste-section
North Carolina Electronics Management Program - http:l/deq.nc.gov/abouVdivisions/waste-managementlelectronics-management
North Carolina Septage Program - https://deq.nc.gov/about/divisions/waste-managementtwaste-management-rules/septage
NC Solid Waste Invoice Form 1-2016

PAID
FIRM NAME: Shorties Pot O Gold
PERMIT #:
NCS-01341
AMOUNT:
$SSO
PAID BY:
Check
DATE:
10/20/2020
Adam Ulishney