NCS00711_2023Permit_Initial

2023
Permit and Registration
P D Quik
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-000711
o and registered as a
��DEQ
E� Q'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. Town of Mount Airy WWTP, Mount Airy, 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 Perry Sugg
Sugg Date: 2023.02.16
10:37:27-05'00'
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 "Finn namee must be exactly as it is shown on your vehicle(s)).
Street address of office:
City:_ 1 � b - StateZip:
Mailing address (if different): --s i �M': �_
City: State: Zip
Phone: J� '�� Fax:
E-Mail: N-11, rtim
County: .'-,>ul
(2.) Firm owner's name:
Septage Management Firm permit number. NCS # / LJ
—
Mailing address (if different): �k C_�_
City:
Phone:
S
State: Zip
(3.) Firm operator's name: Firm operator's title:
Mailing address (if different):
City:
Phone:
State: Zip:
Fax:
(4.) Type(s) of septage pumped: Write in the number of gallons oumoed in last 12 months (Example: Domestic: 50,000).
Domestic I Portable Toilet Waste I Grease (Restaurant) Treatment Plant Industrial/Commercial
/14 n I I n /r r',
(5.) N C. Counties of 0 eratio`:�U� i C;Z6 , did1�� a -L L
(List each county you are authorized to do business in)
(6.) Total Number of Pumper Vehicles Operated: 1-t
Number. used for: Domestic Septage: _ Grease (restaurant):
Other: Portable Toilet Waste:
Vehicle Information: (use additional paper if needed)
License Tag #
I Vehicle Identification #
Tank Capacity
G
rr S
2
� I
Lc A o N _-tg; ay
-,-�
4
P
6M
' p Z-fs .
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) V) 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 C �.�Date �Q "
(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 Completed:
Date: � , '=�n - , Location: Hours:
Training Sponsored or Provided by:
(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: C
Registered Portable Sanitation and Septage Management Firm:
Certification Statement
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 (Signature of c yofficial required)
Print Name
Date
Title "
l I -_-�)© -J'2L
Other Comments:
tj 1 t b Z(r,` �6v �L( ,(�� T Ir
Rev. 04-26-2021
PAGEu�2 / N Y

CITY OF .rVIOUNT AIRY
P.O Sox 70
Mount Airy, NC 27030
SEPTIC WASTE DISCHARGE PERMIT
Septic Waste Discharge Permit (SWDP) to
Discharge septic waste under the
Industrial Pretreatment Program
SWDP Number #0003
In compliance with the provisions of the City of Mount Airy Sewer Use
Ordinance and all other lawful standards and regulations promulgated and
adopted by the North Carolina Division of Water Quality, the following
company and/or individual, hereby referred to by name or as the permittee:
P.D Quik
133 Mason Road
Mount Airy, NC 27030
Is hereby authorized to discharge septic waste into the headworks of the
wastewater treatment facility of the City of Mount Airy in accordance with
limitations, requirements, and all other conditions set forth in this Septic
Waste Discharge Permit (SWDP).
This permit shall become effective July 1, 2022.
This permit and the authorization to discharge shall expire at midnight on
June 30, 2023.
Signed this 41 day of 2022.
Q � ,
Christopher S. Marion
WWTP Supervisor