NCS00330_2023Permit_Initial

2023
Permit and Registration
North State Pumping Service
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-00030
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. Lexington Regional WWTP, Lexington, NC
2. Solid Waste Compost Depot, SWCD 29-10
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, 2023.
12/12/2022
Perry Sugg, EnOronmerAarCornpliance Branch Head

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
G
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)).
- 0( I k S"- Rnm 'n .9rxJr1,-(1
Street address of office: 3 $'7 R 18 . S i:, kC IZrs.
City: i. f l r1A iv-r\ State: M L Zip: P--7 a-cl 5
Mailing address (if different):
City:
Phon
State:
Fax:
Zip.
E-Mail: IJO1 TW,-!,*&4e Qatb �n� i) q A-,aI I ,cry►
County: vrdSo ^ Septage Management Firm permit number: NCS # 00.j3-6
(2.) Firm owner's name: Gin S; n k
.11
Mailing address (if different): SAN-'-
City:,
(3.) Firm operator's name: Rv6e-fT q0L
Mailing address (if different):
City:
Phone:
State: Zip
Fax:
Firm operator's title: O pO,r k
State: Zip:
ax:
a
lk
zw
U a
(4.) Type(s) of septage pumped: Write in the number of gallons pumped in last 12 months (Example: Domestic: 50,000).
Domestic Portable Toilet Waste Grease (Restaurant) Treatment Plant Industrial/Commercial
9,.s00 j 3ov,g00 /2, 08a
(5.) N.C. Counties of Operation: _ baU 00-5 r) aasi9,�(� G,� � I d { [AW1 54kes ; PG.ba►wws
(List each county you are authorized to do business in)
(6.) Total Number of Pumper Vehicles Operated:
Number used for: Domestic Septage: I
Other:
Vehicle Information: (use additional paper if needed)
Grease (restaurant): Z
Portable Toilet Waste:
License Tag #
Vehicle Identification #
Tank Capacity
9300
1
A I 5i
-LW49H1n-70HM114
931P
2
A t44Lt 5q-
t M ZOb tap. 50"1 c"13-
2svo
3
4
5
APPLICATION CONTINUED ON PAGE 2
PAGE 1

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
(CONTINUED FROM PAGE 1)
(7.) Do you plan to operate pumper vehicles? (check one) (✓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 Initial f2a E —Date—It
(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 theSeptage 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: _ SDTF#: Expiration Date:
(9.) Septage Management Firm Operator Training Complete.;
Date: 3-I-1-7-2- Location: L_ �',an
Training Sponsored or Provided by: A
(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: q
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.
grtat:ure (Signature of company official required
nrn Sin
Pant Name
Other Comments:
l�-ti2-22
Date
Ow nel�
Title
PAGE 2
Rev. 04-26-2021

NC SF PTAGF MANAGEMENT FIRM
Recertification of Pumper Vehicle(s)
Septage Firm Permit #: NCS- D 330
Number of Pumper Vehicles: _
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."
Sign ure (Sign!5p�o�pany official required)
/ [ Ae,r (m
Print Name
//-/7.2z
Date
pD�e�ra��L
Title
S:lSolid_WastelcialseptagelformslPumper Vehicles Cetification.doc

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, 1r1i�VIA INc, � (.sue n-
(Plant Operator In Responsible Charge (ORC), License N
1V10-9A
(Address)
0 q.-OL W W
, Name of Plant)
C33 (; . �L—
(Phone Number) (Owner/Operator &Aeptage Management Firm)
of
(Septage
Name and NCS number)
to dispose of: domestic septage �, portable toilet waste
grease Septage (grease trap pumpings) commercial/industrial septage from
sa v,116
(County or othtad Geographic Arm)
at the above named wastewater treatment facility. Septage shall be discharged at:
OO
between the hours of
oAd t
(Location)
-2` r
919 300
%# W 3
30
C_ r24-24Z
Reintroducing partially treated liquid into a grease trap is acceptable Yes k.;" No
This authorization shall be valid until ) �2-! 3 / [ '�-O 2-3
(Usually December 31, Year)
1
Signed Date f f� �- Z
(Facility Operator)
Subscribed and affirmed before me this
(Notary Public)
a
dayof NUyem)p"V20 a
My Commission expires: UQ _,;G ^ 00a-7
Jamie FrMbi
AL SEA)
Notary
Davidson County, NC
Note: Falsification of this document by the septage management firm shall lead to permit revocation.
S:/Solid Waste/CWSEPTAGE/FORMS/2018 Firm Application/WWTP Authorization Form 2018

AUTHORIZATION TO DISCHARGE SEPTAGE AT A SEPTAGE TREATMENT OR
STORAGE FACILITY PERMITTED TO SOMEONE OTHER THAN YOURSELF
(This form is used by a detention or treatment facility permit holder to indicate that permission
has been given to a permitted Septage Management Firm to discharge septage into the permit
holders detention or treatment facility.)
1, Jason Gibson
(Facility Operator)
588 Free Pilgrim Church Rd. Thomasville, NC 27360
(Operator Address)
Robert Yancy
do hereby authorize:
(Owner of Septage Management Firm)
North State 00330
Pumping _ NCS # - - - -
(Name of Septage Management Firm)
316 R.B. Sink Rd
---Lexin8tnn..-NC 2Z9
(Address of Septage Management Firm)
SWCD-29-10
to utilize septage detention or treatment facility 9 - for the treatment or storage of
Septage *
in 20 23 . The facility will be operated in accordance with the Septage Management Rules **_
11 /11 /2022 -
(f acility Operator)
As defined in G.S. 130A-290(a)(32)
As defined in 15A NCAC 138.0800
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