NCS00217_2023Permit_Initial

2023
Permit and Registration
Jefferson Rent -All
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-00217
o and registered as a
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NORTH
EQ
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-�� Septage Management Firm�� �� w� ��nffii�utr
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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. Town of Boone WWTP, Boone, NC
2. Town of Jefferson WWTP, Jefferson, 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, 2023.
Digitally signed by Wm Perry
Wm Perry Sugg Sugg
Date. 2023.02.02 12:23:51-05'00'
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*
Jefferson Rent -All
The "Firm name" must be exactly as it is shown on your vehicle(s).
Septage Management Firm permit number (NCS #)
NCS-00217
Enter the five digits following the NCS #
Street address of office*
Street Address
427 South Main Street
Address Line 2
City
Jefferson
Postal / Zip Code
28640
County*
Ashe
Mailing address same as street address of office?*
• Yes No
Phone*
3368468136
State / Province / Region
North Carolina
Country
United States
Fax
3368468137
Email*
[e-mail]
Owner Info}
Firm owner's name*
Shirley A. Church
Mailing address same as street address of office?*
• Yes No
Phone* Fax
3368468136 3368468137
Operator Info
Firm operator's name* Firm operator's title
Shirley A. Church Owner
Mailing address same as street address of office?*
0 Yes No

Phone* Fax
3368468136 3368468137
Type and amount of septage pumped in the last 12 months
Amount in gallons*
Domestic
0
Portable Toilet Waste
92,967
Grease (Restaurant)
0
Treatment Plant
0
Industrial/Commercial
0
North Carolina counties of operation
List each county you plan to do business in: *
Ashe, Watauga, Avery, Wilkes, Alleghany
Vehicle Info
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*
10/28/2022
Title*
Owner
Choose how to add vehicle descriptions*
• Add vehicles individually Upload List
Pumper
Vehicles
Usage*
License
Tag #*
Vehicle Identification #*
Tank Capacity*
Portable
Toilet
Waste
KX-2525
1HTKJPVKlLH671629
400
Portable
Toilet
Waste
JY-1110
1GB3KYCY8JF156572
450
Portable
Toilet
Waste
BY-2833
1GBE4C3267F410855
400
Portable
Toilet
Waste
AH-4959
1GDE4C3206F402305
400

Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Approved wastewater treatment plant*
• 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* Expiration Date* Authorization
Jefferson Wastewater Treatment 12/31/2023 TJWWTP.PDF 77.9KB
Facility
Town of Boone Wastewater Treatment 12/31/2023 TBWWTP.PDF 92.46KB
Plant
Septage Land Application Sites (SLAS)
Yes • No
Septage Detention or Treatment Facility (SDTF)
Yes • No
Other disposal method*
Yes • No
Septage Management Firm Operator Training Completed
Date* Hours*
8/13/2022 4
Location*
Morganton, North Carolina
Training Sponsored or Provided by*
NC Pumper Group & NC Portable Toilet Group
Septage Land Application Site Operator Training Completed
Date Hours
0
Location
Training Sponsored or Provided by
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
Certif cation 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
6r. 1l5'6y rrt"�
Date
10/28/2022
11:09:48 AM
Print Name* Title*
Shirley A. Church [e-mail]

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.
e IT"
c , �/ 6
i, (GrA4,C -JV Z YNN)
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
.0
ZD 1 C'4 s" "/ r!, a r >a Too" IV L- 2' (-&O —7
�i (Address)
do hereby authorize .��. e rScrtft-_.1'7l SYl
(Phone Number) (Owner/Operator of Septage Management Firm)
of -� e- �cc r-So"'- �cJ-Al' NCS 4 Oo21 i
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage , portable toilet waste
grease septage (grease trap pumpings) commercial/industrial septage , from
Ash. 0a 4il-11 OL- . �A'IX .1, Laj14es
or other Geographic Are
at the above named wastewater treatment facility. Septage shall be discharged at:
Heccao rev-;
(Location)
between the hours of `� .- c)o f4-M — i - r)uP-t
Reintroducing partially treated liquid into a grease trap is acceptable Yes *' No
This authorization shall be valid untii -� '�`C�rfn. 1 SkZU z,
(Usually De ember 31, Year)
Signe `} Date
(Facility Operator)
�h
Subscribed and affirmed before me this day of �! 20
W My Commission expires:
(Notary Public) �y
0 (qFA ofta XLA�)
North Carolina
Ashe Count
Note: Falsification of this document by the septage management firm shall lead to permit revocation.
5:/Solid_Waste/CLA/SEPTAGE/FORMS/2018 Firm Application/WWTP Authorization Form 2018

AUTHORIZATION TO DISCHARGE SIEPTAGE 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.
(Plant Operator in Responsible Cha
IXAA1. II.h N
(ARC), ORC License Number, Name of Plant)
(Address)
do hereby authorize
C
(Phone be ( /n—e Number) /� /(Owner/Operator of Septage Management Firm) ,cl n
:R
117
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage _, portable toilet waste
grease septage (grease trap pumpings) _ commercial/industrial septage __ _, from
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
between the hours of
Reintroducing partially treated liquid into a grease! trap is acceptable Yes N❑
This authorization shall be valid until
DELLM6[ 3/4 pt'�Z�'
(Usually D&ember 31, Year)
Signed Date O
(Facility Operator)
Subscribed and affirmed befo a me this _ G 0
f day of t_J � � 20
�LJC My Commission expires:
(Notary Public)
-. KARI:N COOK
�'� OFFI,.,f��t! ��ublic
t' moo` t i C olina
Ashe County
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