NCS00321_2023Permit_Initial

2023
Permit and Registration
Goldston's Concrete and Septic Tanks, Inc.
is hereby issued a Septage Management Firm Permit,
ZNti STATE ,,0. " Permit Number NCS-00321
o and registered as a aw-g� E
e:,e D
E� M
-�� Septage Management Firm ��en� �� w� nmenta�llty
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. City of Asheboro WWTP, Asheboro, NC
2. Town of Siler City WWTP, Siler City, 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.
" �7 11 /28/2022
Perry Sugg, Envir mental mpliance Branch Head

APPLICATION FOR PERPMT 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)).
461A,oris_ �,'mc evAy a nA
Street address of office: 1553 NL N ic���ua►► � N a�i _
j ►
City: L , W 59.Xr _ State: _Zip: A 731(o
Mailing address (if different): _I� C) �j 0 '73 7
City: ik rr= _ State:
—N-C-,--Zip a 7,31
Phone: Fax:_33A _ 92 7 5 2 6
y
County: J VULD dio� i Sep ge Management Firm permit number: NCS # 00311
(2.) Firm owner's name: 1,, care 1-. `C.ry� fit; y► _ ___
Mailing address (if different): ZARM g CA V It,
City:
State: —
Phone: Fax:
Zip -
(3.) Firm operator's name:_,!Ajjjk�, 'Pirm OWAtY` Firm operator's title: `77tcr slt�'�''
Mailing address (if different): _ 3ift _ \1 S_ 4bg 'N
City: _
State: — Zip:
Phone: — Fax:
(4.) Type(s) of septage pumped: Write in the number of gallons oumoed in last 12months (Example: Domestic: 50,000).
Domestic I Portable Toilet Waste I Grease (Restaurant) I Treatment Plant IndustdaVCommercial
(5.) N.C. Counties of Operation: �a►n�% `l7lal�r�
each county you are authorized to do business in)
(6.) Total Number of Pumper Vehicles Operated: l
Number used for. Domestic Septage:_ Grease (restaurant): ✓
Other: Portable Toilet Waste: _
Vehicle Information: (use additional paper if needed)
License Tag #
L aR D),
2
4
5
APPLICATION CONTINUED ON PAGE 2

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
(CONTINUED FROM PAGE 1)
(7.) Do you plan to operate pumper vehicles? (check one) (Ryes ( ) 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? (x) yes ( ) no Initial Date I 1 V
(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:
Septage Detention or Treatment Facility (SDTF) Permit Numbers: (use additional sheets if needed)
SDTF#: Expiration Date: SDTF#: Expiration Date:
(9.) Septage Management Firm Operator Training Completed:
Date: 91/1 LR Q 81- Location: _ � ree n �� ors NG Hours:
Training Sponsored or Provided by: N c .5 1 R
(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
6
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 (SignaMm f ca , panyofficiat mquired)
Print Name
Other Comments:
I►�I���.Q�Z
Date
-Frtzsttmy—
Title
PAGE 2
Rev.04-26-2021

NC SEPTAGE MANAGEMENT FIRM
Recertification of Pumper Vehicle(s)
Septage Firm Permit #:
Number of Pumper Vehicles
NCS-
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."
A % L&5�- --
Signatun: (SignkurVof company official required)
rr tza \d 5xan
Print Name
11
Date
j rev
Me
S:%Solid WastelclalseptagelformslPumper Vehicles Cetification.doc

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.
I, Michael R. Wiseman ORC WW4#987680 City of Asheboro Wastewater Treatment Plant
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
1032 Bonkeme er Drive, Randleman NC 27317
(Address)
336-672-0892 do hereby authorize Larry Goldston
(Phone Number) (Owner/Operator of Septage Management Firm)
of Goldston Concrete Inc. NCS# 500 321
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage X portable toilet waste
grease septage (grease trap pumpings) X commercial/industrial septage from
Randolph County
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
1032 Bonkeme er Drive Randleman, NC 27317
(Location)
between the hours of 7:00 a.m. to 5:00 p.m. Monday - Friday Onlv
Reintroducing partially treated liquid into a grease trap is acceptable Yes X No
This authorization shall be valid until December 31 2023
(Usually December 31, Year)
Signed - - a Date /0,1V0/2-7—
(Facility Operator)
Subscribed and affirmed before me this
k U�
day of (_ _.[. _ A c.20 z�
My Commission expires: Z_jba;_
(Ibtany Public) %% I s,gW�ry�
CL" (O AL SEAL
r A y
0:
9 �DUB�-�G �2►
Note: Falsification of this document by the septage management firm shall lead to permit ALMation.
S:/Solid_Waste/CLA/SEPTAGE/FORMS/2019 Firm Application/WWTP Authorization Form 2019 ii�lot PH'

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.
Brittany York, 1007288, Town of Siler City
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
PO Box 769, Siler City, NC 27344
(Address)
919 742-4581 do hereby authorize Lang Goldston
(Phone Number) (Owner/Operator of Septage Management Firm)
of Goldson Concrete and Se tic NCS # 500321
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage X , portable toilet waste X
grease septage (grease trap pumpings) No commercial/industrial septage No , from
Chatham County
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
Headworks
(Location)
between the hours of Mon - Fri 7:00 am - 4:00 pm
Reintroducing partially treated liquid into a grease trap is acceptable Yes X No
This authorization shall be valid until
Dec. 31, 2023
(Usually December 31, Year)
Signed l7 Date & J ZR FIZZ.
(Facility Operato )
-� &:Lh
Subscrib d affirmed before me this [ day ofnNanr20
My Commission expires:
(Notary Public)
ao0601A19B1lADp°®
�m �Q•o �`ystion
r�
V : C)
Note: Falsification of this document by the septage management firm shall leakt mitptp#Nt&oR Z
S:/Solid_Waste/CLA/SEPTAGE/FORMS/2018 Firm Application/WWTP Authorization Form 2018 %' S���••.�
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North Carolina Department of Environmental Quality
Division of Waste Management INVOICE
NORTH CAROLiNA
EnAmimental Quality Solid Waste Section
Division of Waste Management To: Larry L. Goldston
Solid Waste Section Goldston's Concrete and Septic Tanks, Inc.
1646 Mail Service Center PO Box 737
Raleigh, NC 27699-1646 Ramseur, NC 27316
Phone/Fax: [phone]
Email: [e-mail]
Date: 09/27/2022
Invoice #: NCS-00321-2023
Septage - Annual:
Goldston's Concrete and Septic Tanks, Inc. (NCS-00321)
PO Box 737 $550.00
Ramseur, NC 27316
Number of Trucks: 1
Date Due: 12/15/2022
LATE FEES: In accordance with NC General Statutes GS 130A-2911(e2), a late fee will be applied to any annual permit fees not submitted oy January 1, 2023
Payment Options:
E-check Available online at httpsWc1eq.nc_gov/swpav
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 https://deq.ncjov/swnav
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 retumed checks.]
Explanation anation of Invoice Amount is Based on Firm'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.
For questions regarding_
Billing Jared Wilson [phone]
Regulations or Technical Assistance Chester Cobb [phone]
Jeffrey Bullard [phone]
More information available on the web:
North Carolina Department of Environmental Quality (DEQ) - .
North Carolina Solid Waste Program - htti.sa. de
North Carolina Septage Management Program - _. abou /divisions
handling/septage
PAI
CK. NO.
4030
DATE
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Solid