NCS00207_2023Permit_Initial

2023
Permit and Registration
Rouse Septic Tank Service
is hereby issued a Septage Management Firm Permit,
STATE,, _ Permit Number NCS-00207
oand registered as a e:,e D Qi�
NORTH
A%L 12. rim
-�� Septage Management Firm�� �� w� ��nffii�utr
4sr
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 Land Application Site, SLAS 16-03, SLAS 16-05
2. Septage Detention or Treatment Facility, SDTF 16-05
3. Moorehead City WWTP, Moorehead 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.
" A�12/14/2022
Perry Sugg, En ' nmenta ompliance Branch Head

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
DIVISION OF WASTE MANAGEMENT - SOLID WASTE SECTION -1646 MAIL SERVICE CENTER, RALEIGH, NC 27699.16446
(1.) Firm name: (The "Finn name" must be exactly as it is shown on your vehicle(s)).
Street address of office: ZA 3 ! 57%� SSA V
city:. Acgw A&1* State: . G. Zip:. 9 1sp0
Mailing address (if different):
City:
Phone:
E-Mail:
State: Zip:
Fax:
County: G AA 741, 0.7 Septage Management Firm permit number: NC3 #
(2.) Firm owner's name: ij�AvOAe P7 e. MOIL
Mailing address (if different):
City:
State: Zip:
Phone: _ AS.Z- %G• 6 !G/ Fax: _ -9 5;2 ' 7 a G - aG 3/
(3.) Firm operators name: &%LY A 05'1G* Firm operator's title: PA45WdC4.7
Mailing address (if different):
City:
State: Zip:
Phone: .25,2 - % oG - G 7G/ Fax: 15'2 - 7 0G - OG3/
(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
a �r
(5.) N.C. Counties of Operation: _ e. X 74CA0 7 -
(List each county you are authorized to do business in)
(6.) Total Number of Pumper Vehicles Operated: A
Number used for: Domestic Septage: Grease (restaurant): _
Other: Portable Toilet Waste:
Vehicle Information: (use additional paper if needed)
License T2g #
Vehicle Identification #
Tank Ca acit
1
X 91567
IV-71y 6,41 AP6 V:0 9174
30
2
- ACA o
o 4°
344
3
4
5
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: ( ) 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#: 140r Expiration Date: �'/3•.�3
c) Septage Detention or Treatment Facility (SDTF) Permit Numbers: (use additional sheets if needed)
SDTF#: /a Expiration Date: /it•"-, 5'-SDTF# Expiration Date: T
(8.) Septage Management Firm Operator Training Completed:
Date: Location: A&La., 4.-.4 Hours:
Training Sponsored or Provided by:
(9.) Septage Land Application Site Operator Training Completed:
Date: Location: NifW 0A&: n Hours:
Training Sponsored or Provided by: ,�4 04pihId^5 CA,♦•I
(10.) 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 knowingly making a false statement, representation, or certification.
Signature (' atu of company official requireo
&LUZ 40�
Print Name
Date
AAEsla. 7
Title
Other Comments: )PA) 0 r/- A o,' O� Lx �v.4 s4A5
w,45 5&40MI770,0
S:/Solid_Waste:/CLAISEPTAGEIFORMS/2018 Firm Application/FirmPermitApplication2018
PAGE 2

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, a s t Eton I L- l 11y1M wW22
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
loob Ty--toAMen+ Box�?,md BbLftod U-+% WC &E61
(Address)
2S2.12le-U231 do hereby authorize
(Phone Number)
I/U-,Y A aa. -
(Owner/Operator of Septage Management Firm)
of D y dS T L ^ N ,V _:WCS # D0,1d %
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage _, portable toilet waste ,
grease septage (grease trap pumpings) commercial/industrial septage , from
€7
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
WW
' � l ocation)
between the hours of �1'l'
zs* 'N M
Reintroducing partially treated liquid into a grease trap is acceptable Yes is No
This authorization shall be valid until 3�
(Usually December 31, Year)
Signed Date
(Facility Operator)
Subscribed and affirmed before me this day of GIB 20_
'If, My Commission expires:%'
( otary Public) `,♦♦♦♦♦♦.� � � e �.,,��,,''
(OFFICAQ. -.its 2
a
C) ' o
c _
r1 co > -�
Note: Falsification of this document by the septage management firm shall lead to permit tQJ Wtion -, -�7 O `=
v
S:/Solid Waste/CLA/SEPTAGE/FORMS/2018 Firm Application/WWTP Authorization Form 2018 �' �} _ •• ,'�
r Cj
NC

NC S E PTAGE 1VIANAGEMENT FIRM
Recertification of Pumper Vehicle(s)
Septage Firm Permit #: NCS- O o.2a i
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."
Signature (Signs of company official required)
6 Y x0GSG"
Print Name
//-��• gva
Date
Title
S:lSolid_WastelclalseptagelformslPumper Vehicles Cetification.doc