NCS01377_2022Permit_Initial

2022
Permit and Registration
Island Septic
is hereby issued a Septage Management Firm Permit,
tszArr of
Permit Number NCS-01377
0
o and registered as a e:-e D:;.�EQ2�
` a= Septage Management Firm Department ofEnvironmental Quality
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. Septage Detention or Treatment Facility, SDTF-27-23
2. Septage Land Application Site, SLAS-27-23
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
20:51:05-04'00'
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, N FIECEIV D
(1.) Firm name: (The "Firm name" must be exactly as it is shown on your vehicie(s)). �+�
�sla•+�. S `.=nc... ,1AN 10 2022
Street address of office: Lc1. k 144-1 1i.-&k RA -
City: 1. hl:ai.w State:'�I C Zip: -2-7 9 V 9
�`��-� WASTE SECTIQN
Mailing address (if different): ?' E' LV
City: k, -t 14audl< State: 11 d- Zip. X?q 5�9—
Phone: a SQ- VS-9- 3 3 Fax:
E-Mail: o njR rexLd I - C
County: I A a`46- Sep',tlage Management Firm permit number: NCS # 3 i7
(2.) Firm owner's name:
Mailing address (if different):
City: State: Zip
Phone: Fax:_
R) Firm operators name: T n,ov.+A" oknv- Firm operator's title: ow#1tr
Mailing address (if different):
City. State: Zip:
Phone: Fax:
(4.) Type(s) of septage pumped: Write . ±te in the number of gallons oumned in last 12 months (Example: Domestic: 50,000).
Domestic Portable Toilet Waste Grease (Restaurant) Treatment Plant Indusbial/Commercial
753 Sa S7► Soo _
(5.) N.C. Counties of Operation:
(list each county you are authorized to do business in)
(6.) Total Number of Pumper Vehicles Operated: 3 _
Number used for. Domestic Septage: 3 Grease (restaurant): 3
Other. Portable Toilet Waste:
Vehicle Information: (use additional paper if needed)
License Tag # Vehicle Identification #
Tank Capacity
t
A 1*373/q 6 IV Po- */I PFX q TO VS17944
2
3 Zc
t IV 0-E JXb 7/
3
142- 1%
N P o O/
4
5
APPLICATION CONTINUED ON PAGE 2
PAGE 1

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT ,M
(CONTINUED FROM PAGE 1)
(7.) Do you plan to operate pumper vehicles? (check one) (byes ( ) 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? (✓Eyes ( ) no Initial ��Date C . ro �• oa
(8.) Septage Disposal Method: (check one)
a) Approved wastewater treatment plant: ( ) yes ( pfno. If yes, submit Wastewater Treatment Authorization for each
plant, as indicated in Subparagraph .0834(c)(14) of theSeptage Management Rules.
b) Septage Land Application Site (SLAS) Permit Numbers: (use additional sheets ifneeded)
SLAS#: a_ j .?� Expiration Date: P2. 3 / • A) Ste: Expiration Date:
c) Septage Detention or Treatment Facility (SDTF) Permit Numbers: (use additional sheets if needed)
SDTFIt 2?• 23 Expiration pate: g � SDTF#: Expiration Date:
(9.) Septage Management Firm Operator Training Completed:
Date: /0•/a+In•Iq 20v Location: 36r M-! Q,% 41o9*54%d rJc Hours:
Training Sponsored or Provided by: Q— -14
(10.) Septage Land Application Site Operator Training Completed:
Date: /o -/g +)a -/R
Location: &% /N ; I Pa.(k ty ra-*"4" "" Hours:
Training Sponsored or Provided by: _ d -A"
(11.) Registration type requested: CHECK ONE
Registered Portable Sanitation Firm:
Registered Septage Management Firm:
Registered Portable Sanitation and Septage Management Firm:
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 knowi9�ly making a false statement, representation, or certification.
.�
S ure (Sig ure of companyofficial required) Date
'ao aAeaN A-1--
Print Name '
Other Comments:
gwine-c
Two
Rev. 04-26-2021

AUTHORIZATION TO DISCHARGE SEPTAGE AT A SEPTAGE LAND APPLICATION
SITE PERMITTED TO SOMEONE OTHER THAN YOURSELF
(This form is used by a land application site permit holder to indicate that permission has been
given to a permitted Septage Management Firm to land apply septage on the permit holders
land application site.)
(Site Operator)
Q /too dr. P6�c L-1 q4e. - IVaA Ism A. F eJdL
Operator Address)
s
do hereby authorize:
(Owner of Septage Management Firm)
NCS # -0 t3.7'7
(Dame of Septage Management Firm)
(Septage Management Firm Address)
to use septage disposal site #-4Q&'g21Aor the disposal of / W aoa gallons of septage* in 20AV--
Date: Dec
Signed _
(Site Operator)
* As defined In G.S. 130-A-290(a)(32). The site will be operated in accordance with 15A NCAC 13B
.0800 - Septage Management Rules
Return the properly completed form to:
North Carolina Department of Environmental Quality
Division of Waste Management
Solid Waste Section
1646 Mail Service Center
Raleigh, NC 27699-1646

202.1
Permit and
t. -at
ion
Island Septic
.P is hereby issued a Septage Management � r � � • �, iP $� Firm Permit,
WO Permit Number .NCS-01377
And b virtue of ccsmpletin the annual traini
y g ng:f
requirements is hereby registered as a
-X� 1 r cA,vou�n D"
y��yj��,�yn4! Rualh
NORTH CAROLntolQu ltr Septage .1�✓Ianagernent Firfn
Enviranmenrul Qur�liry
in the State of North Carolina.
Phis permit to operate a Septage Management Finn is issued to the above named person, business or entity at atnd is not r:insfc able to any other person business or emit
Finn operation small be in accordance %vitll the provisions of N.C. General Statute 130A-291 1 - 130Aentity Title 15A of the N.C. Administrative Code son .0 0
conditions of the permit, and representations made in the application and accompanying documents for a ,permit. 13B)
8 0 et.seq.,
The pemnit holder is authorized to discharge septage only at the locations(s) listed below:
1. Septage .Detention or 'Treatment Facility, SD'TF- 27-23
2. Septage Land Application Site, SLAS- 27-23
This permit does not entitle the permit holder to operate a Septage hand Application Site, a
not specified herein 5eptage Detention or Treatment Facility, or any other solid waste management fac
ility
Gutty
Failure to operate as permitted may result in the Deparhnent 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, 2021. g
Digitally signed byAdamA am U!ishneyUllshney
Date: 2021.08,23 13.0910-04'00'
Adair Ulishney, Environmental Compliance Branch Head

'V"
First Name
U,J�S
ast Name
Received Credit Hours
of Continuing Education
T •
1 ins k.erttticate of Attendance Presented By;
N CST
NORTH CAROLINA SEPTIC TANK ASSOCIATION
Hours Accredited by:
NCOWCICB
NC Division of Waste Mgmt
Septage Firm Mgmt 4 Hours
REHS Board
WPCSOCC CE03191906 (Subsurface Operator
❑ Other:
Important: Keep this in a safe place.
Date:
Signed:
Jerry O. Pearce, NCSTA President
Duplicates are not available.
2021

First Name Last Name
Received Credit Hours
of Continuing Education
This Certificate of Attendance Presented By:
rd CSTA
NORTH CAROLI NA SEPTIC TANK ASSOCIATION
Hours Accredited by:
NCOWCICB
NC Division of Waste Mgmt
Septage Firm Mgmt 4 Hours
REHS Board
WPCSOCC CE03191906 (Subsurface Operator
❑ Other:
Date: j 2021
Signed:
Jerry 0. Pearce, NCSTA President
Important: Keep this in a safe place. Duplicates are not available.

FIRM NAME: Island Septic
PERMIT #: NCS-01377
AMOUNT: $800
PAID BY: E-Card
DATE: 12/31/2021
Adam Ulishney