NCS00522_2023Permit_Initial

2023
Permit and Registration
Chuck Keene Septic Tank Pumping
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-00522
o and registered as a
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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. TZ Osborne WRF, McLeansville, NC
2. City of High Point Eastside WWTP, Jamestown, 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
Wm Perry by Wm Perry
Sugg
Sugg Date: 2023.02.02
13:16:02-05'00'
Perry Sugg, Environmental Compliance Branch Head

North Carolina Department of Environmental Quality
Division of Waste Management INVOICE
vcara on€?o::,,A u:r:.a Solid Waste Section
�,.rvFst: i
Division of Waste Management
To:
Jimmy Carl Keene
Solid Waste Section
Chuck Keene Septic Tank Pumping
1646 Mail Service Center,
3281 Providence Church Rd.
Raleigh, NC 27699-1646
Climax, NC 27233
Phone/Fax: [phone]
Email: [e-mail]
6 52,3
GK. NO,
Date: 09/27/2022
DATE
Ssv.00
Invoice #: NCS-00522-2023
Septage - Annual:
Chuck Keene Septic Tank Pumping (NCS-00522)
3281 Providence Church Rd. $550.00
Climax, NC 27233
Number of Trucks:1
Date Due: 12/15/202
LATE FEES:
Payment Options:
E-check Available online at
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
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 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
Regulations or Technical Assistance
Jared Wilson [phone]
Chester Cobb [phone]
Jeffrey Bullard [phone]
More information available on the web:
North Carolina Department of Environmental Quality (DEQ) -
North Carolina Solid Waste Program -
North Carolina Septage Management Program -

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 vehfcle(s)). OV
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Street address of office: -3 29/ P/'rry r derl ce (f A (4',- C co "—(i
City: 611 MqX State: Zip: 7 Z 3
Mailing address (if different):
City: cs State: Zip: lit tggL°��
Phone: 3% �o - 1y q Fax:
E-Mail: K42efiq /C ,44 /- eXAL
County: 4 r7 0 1 �'1 Septage Management Firm permit number: NCS # �3a Z
(2.) Firm owner's name: ` e 2
Mailing address (if different):
City: State: Zip:
Phone: Fax:
(3.) Firm operator's name: I psi ej 14C' /' f' 2�tsrm operator's title: dGvne/^
Mailing address (if different):
City: State: Zip:
Phone: Fax:
(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
W zw n- I Zd a1W
(5.) N.C. Counties of Operation: L.-r .: ; f rj Ar7b /p A ,OA vl d,5otj
(List each county you are authorized to do business in)
(6.) Total Number of Pumper Vehicles Operated:
Number used for: Domestic Septage: Grease (restaurant):
Other: Portable Toilet Waste:
Vehicle Information: (use additional paper if needed)
APPLICATION CONTINUED ON PAGE 2

PAGE 1
. APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
(CONTINUED FROM PAGE 1)
(7.) Septage Disposal Method: (check one)
a) Approved wastewater treatment plant: (v,")' yes ( ) no. If yes, submit Wastewater Treatment Authorization
for each plant, as indicated in Subparagraph .0833(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: SDTF#: Expiration Date: _
(8.) Septage Manage ent Firm Operator Training Completed:
Date: ��7j�Z0ZZ Location: :'-',c�{'©r /LG
Training Sponsored or Provided by:
(9.) Septage Land Application Site Operator Training Completed:
Date: Location:
Training Sponsored or Provided by:
(10.) Registration type requested: CHECK ONE
Registered Portable Sanitation Firm:
Registered Septage Management Firm: ✓
Registered Portable Sanitation and Septage Management firm:
Certification Statement
Hours: 6
Hours:
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.
Sign tune (Sign t e of company official required
Z5-) rlr7�
Print Name
Other Comments:
/11/s/-26 zz
Date
JWJY7 e!` ✓d�4� 0l�
Title
SJSolid_Waste:ICLAISEPTAGEIFORMS12018 Firm Application/FirmPermitApplication2018
PAGE 2

NC SEPTAGE MANAGEMENT FIRM
Recertification of Pumper Vehicles)
Septage Firm Permit #: NCS- JO 52Z
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."
qa
Sig ture (Sigga ture of company official mqui►+eo
y
Print Name
/l 11,5-12,0 zz
Date
Jw,r7-eorAor
Title
S:1Solid_WastelclalseptagelformslPumper 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.
i Bradley Flynt (Grade IV 27171) ORC for T Z Osborne Water Reclamation Facility
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
2350 Huffine Mill Road, McLeansville NC 27301
336-433-7262
(Phone Number)
do hereby authorize
(Address)
Jimmy Carl Keene
(Owner/Operator of Septage Management Firm)
of Chuck Keene Septic Tank Pumping NCS # 522
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage XXX portable toilet waste NO
grease septage (grease trap pumpings) NO commercial/industrial septage NO, from
Guilford County NC
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
City of Greensboro T. Z. Osborne Water Reclamation Facility
(Location)
between the hours of 7:00 a.m. - 6:00 p.m. Monday through Saturday
XX
Reintroducing partially treated liquid into a grease trap is acceptable Yes No
This authorization shall be valid until
December 31, 2023
(Usually December 31, Year)
Signed Date /0`i0 -4,V-
(F ility 0 erator)
Subscribed and lWirmed befo me this / day of �CTo4�/Z 20 ?iv
My Commission expires: —
(Notary Public)
FFIC� CHAVIS
GUiLFORD COUNTY NC
M Commission Ex Tres M 21, 202fi
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

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.
I, John Thomas, Certification # 1000478, City of High Point Eastside WWTP
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
5898 Riverdale Drive, Jamestown, NC, 27282
(Address)
336-822-4730 do hereby authorize
(Phone Number)
Jimmy Carl Keene
(Owner/Operator of Septage Management Firm)
of Chuck Keene Septic Pumping NCS # 00522
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage Yes portable toilet waste Yes
grease septage (grease trap pumpings) No commercial/industrial septage No from
Guilford, Randolph, Davidson, Forsyth
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
Eastside WWTP Se�:ta:. a Receiving. Station
(Location)
between the hours of 7:00 AM - 5:00 PM Monday - Sunday
Reintroducing partially treated liquid into a grease trap is acceptable Yes X No
This authorization shall be valid until
Signed •a�^ �^�-,�^-�'
(Facility Operator)
Subscr'bed and affirmed before me this
December 31, 2023
(Usually December 31, Year)
Date to / ZS/ zZ.
day of 20 Z-Z
q ��3
My Commission expires:
(Not y Pu lic) `t%%11111111/.�
G QyR,,,
(AL SEAL)
N�
,OTAgy
do
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Note: Falsification of this document by the septage management firm shall lead to perri*71RocationL` =CUB
S:/Solid_Waste/CLA/SEPTAGE/FORMS/2018 Firm Application/WWTP Authorization Form 2018 �1j
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