NCS00594_2023Permit_Initial

2023
Permit and Registration
Street Septic Tank Service
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-00594
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. City of Roxboro WWTP, Roxboro, 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 PerrySugg
Sugg Date: 2023.02.16
10:27:38-05'00'
Perry Sugg, Environmental Compliance Branch Head

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
DIVISION OF WASTE MANAGEMENT - SOLID WASTE SECTION -1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646
(1.) Firm name: (The "Firm name" must be L as it is shown on your vehicle(s)).
r xGe v'sv ice;
street address of office: r' A 4 0©n es LP-5 +--r- ►— lka cL
City: State: tJ C Zip: Zr7 5'
Mailing address (if different):
City; State: Zip
Phone3 .5 Fax:
E-Mail:_ Sf�� h �52Gb �� act h �. C.c>rv►
County: PerSonl _Septage Management Firm permit number. NCS # 51H
(Z) Firm owner's name: QS4-rr_e_-f-,j
Mailing address (if different):
City: State: Zip
Phone: Fax:.
(3.) Firm operator's name ass .Sfr 1 Firm operator's W: ear
Mailing address (if different):
State: Zip:
Phone. Fax:
(4.) Type(s) of septage pumped: Write in the number of gallons numoed in iast 12 months_ (Example: Domestic: 50,000).
Domestic Portable Toilet Waste
Grease (Restaurant)
Treatment Plant
Industrial/Commercial
33 , oo0
(5.) N.C. Counties of Operation: ��►''50f.1
(List each county you are autlwrired to do business in)
(&) Total Number of Pumper Vehicles Operated:
Number used for Domestic Septage:
Other.
Vehicle Information: (use additional paper if needed)
Grease (restaurant):
Portable Toilet Waste:
License Tag #
3I
Vehicle Identification #
Tank Capacity
1
FDWFBCGSwv 11 5'7
2
YA 11100
S
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 cerfify that a tog is maintained of each septage pumping event as
required by 15A NCAC 13B .0836(a). I am aware that theme are significant penalties for false certification including the
possibility of fine and imprisonment."
Do you attest to the statement above? ( ) yes ( ) no Initial S DateZ-I_
(8.) Septage Disposal Method: (check one)
a) Approved wastewater treatment plank ( ) yes ( ) no. if yes, submit Wwtewater 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)
SDTFt Expiration Date: SDTF#: Expiration Date:
(9.) Septage Management Firm Operator Training Completed:
Date: 4 o_ zoz: - Location: i N C Flours:
Training Sponsored or Provided by: CC a C -o� .
(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:
Certfication Statement
7:711V
I certify that the information and representations in this appkation for a permit an: 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.
Sig (Signature of companyofficia required)
ves5 e� iV—e "AY —
Print Name
Other Comments:
2 2 2DZ�
Date
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Titre
PAGE 2
Rev. 04-26r2021

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, Derek Clayton, ORC #9264 for the City of Roxboro VWVfP
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
902 Cavel-Chub Lake Rd. Roxboro NC 27574 (NC0021024
336 599 8232
(Phone Number)
(Address)
o hereby authorize Jessie Street Jr.
(owner/Operator of Septage Management Firm)
of NCS # 005 4
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage YES , portable toilet waste NO
grease septage (grease trap pumpings) NO commercial/industrial septage NO , from
Person County NC (only!) Domestic Septage (Only!) -
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
Septic Dumping Station at the head of the Roxboro WWTP located at 902 Cavel-Chub Lake Rd.
(Location)
between the hours of 6 30a'n-' 1:30am 81Z30pm-6p'n (later by pem"ss'°n only)
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 �-� �-� Date. /2--ZozZ
(FacilityOperator)
Su cribed and affirmed before me this 6 !-2 day of 20
Zf—
My Commission expires: 11?oZ-7
' (Notary Public) 0
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Note: Falsification of this document by the septage management firm shall lead to t rjavocatign:,�����
S:/Solid_Waste/CLA/SEPTAGE/FORMS/2018 Firm Application/WwrP Authorization Form 2018 � SIN CO�� %%`

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North Carolina Department of Environmental Quality
r ''~ Division of Waste Management INVOICE
NORTH CAROUNA Solid Waste Section
Enrironmentar Quality
Division of Waste Management
Solid Waste Section
1646 Mail Service Center
Raleigh, NC 27699-1646
Phone/Fax: [phone]
Email: [e-mail]
To: Jessie Street Jr
PAi .1
CK NO. l o763
DATE 12 -Zt-'22 .
000. oo
Septage - Annual:
Street Septic Tank Service (NCS-00594)
704 Jones Lester Rd
Roxboro, NC 27574
Number of Trucks: 2
Street Septic Tank Service
704 Jones Lester Rd
Roxboro, NC 27574
Date Due:
Date.- 09/27/2022
Invoice #: NCS-00594-2023
$800.00
LATE FEES: accordan, o BOA-2,,l ,f.° ') iat, j e %v l - not submitted . - ranuary
Payment Options:
E-check Available online at I
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' < - i ; : .
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 returned chedcs
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 r ardi
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) - i
North Carolina Solid Waste Program
North Carolina Septage Management Program -