NCS00830_2023Permit_Initial

2023
Permit and Registration
Queens Septic Tank
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-00830
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 High Point Eastside WWTP, Jamestown, NC
2. City of Asheboro WWTP, Randleman, 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.
Wm Perr Digitally signed by
Y Wm Perry Sugg
Sugg 114 19 20— 7 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 27699-164
(1.) Firm name: n (T�t' e "Firm name" must be ex- actly as it is shown on your vehicle(s)).
1 C--- ..
Street addr s of f�c: �`t1.j�Lj �.
City: (' State
Mailing address (if different):
City:
State; Zip:
County: )Ctnc ?010h Septage Management Firm permit number: NCS # MOD
(2.) Firm owner's name: l
(3.)
Mailing address (if different):
City:
State: Zip:
Phone: 3 - t`37d -11 14L) Fax:
Firm operator's name: r ��--
Mailing address (if different):
City:
Firm operator's title: Of0nrQ+?)/-
State: Zip:
Phone: '334- a?o — i I q 4 Fax.
(4) Type(s) of septage pumped: Write in the number of gallons pumed in last 12 Months (Example: Domestic:
50,000).
(5.) N.C. Counties of Operation: tag 1�-�i �a►r�n1® t ���P,�QnC51J'
(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: i
Vehicle Information: (use additional paper if needed)
License Taq #
Vehicle Identification
OL'
APPLICATION CONTINUED ON PAGE 2

APPLICATION FOR PERN'TIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
(CONTINUED FROM PAGE 1)
(7.) Do you plan to operate pumper vehicles? (check one) (✓Dyes ( ) 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? (,/Iyes ( ) no Initial W11 Date ja- J!`t:�2+
(8.) 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 .0834(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: _
(9.) Septage Management Firm Operator Training Compl ed: /
Date:_ Location:Hours:_ �P
Training Sponsored or Provided by: r QC5 Tft
(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:
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 ( nature of company official required)
r
Print Name
Other Comments:
-
Date
PAGE 2
Rev. 04.26-2021

NC SEPTAGE MANAGEMENT FIRM
Recertification of bumper Vehicle(s)
Septage Firm Permit #: NCS-
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 nature ofcompanyofficial requirso
Print NarneJ
Date
S:1Solid_WastelclalseptagelfonnslPumper Vehicles Cetification.doc

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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 Ci of Hi h Point Eastside WWTP
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
336-822-4730
(Phone Number)
5898 Riverdale Drive Jamestown NC 27282
(Add ress)
do hereby authorize Roger Queen II
(Owner/Operator of Septage Management Firm)
of Queens Septic Tank NCS # 00830
(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 Septage Receiving Station
(Location)
between the hours of 7:00 AM - 5:00 PM Monday - Sunda
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 �k ' ' Date e o L Z
(Facility Operator) %� //
Subscribed and affirmed before me this �` day of t� �" 20 Z
` G-��� My Commission expires: "` y. Z?JZj
(NotaK Pu ic) `,,1111111JII�I
G e'qq ii
i'CIAL SEAL)
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O AUBL\G V
Note: Falsification of this document by the septage management firm shall lead to per vocation.
S:/Solid_Waste/CLA/SEPTAGE/FORMS/2018 Firm Application/WWTP Authorization Form 2018
O/V o` �,

AUTHORIZATION TO DISCHARGE SEPTAGE TO A WASTEWATER TREATMENT FACILITY
North Carolina Department of Environment and Natural Resources
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, Michael R. Wiseman, ORC. WW4#987680. City of Asheboro Wastewater Treatment Plant
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
1032 Bonkemevw Drive, Randleman, NC 27317
(Address)
336-672-0892 do hereby authorize Roger Queen II
(Phone Number) (Owner/Operator of Septage Management Firm)
of Queen's Septic Tank
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage X _, portable toilet waste
NCS# 00830
grease septage (grease trap pumpings) X _ commercial/industrial septage , from
Randolph County
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
1032 Bonkemever Drive. Randleman NC 27317
(Location)
between the hours of 7:00 a.m. to 5:00 p.m. Monday - Frida Onl
Reintroducing partially treated liquid into a grease trap is acceptable Yes X No
This authorization shall be valid until December 31, 2023
W (Usually December 31, Year)
Signed Date I Z Z
(Facility Operator) ,
Subscribed and affirmed before me this _ ;`''I'� day of —ti '�� � •��' 20 ZZ
My Commission expires:
otary Public) VEAL)
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? �pT4gy
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Note: Falsification of this document by the septage management firm shall lead to permit revo�
S:/Solid_Waste/CLA/SEPTAGE/FORMS/2019 Firm Application/WWTP Authorization Form 2019 ��/'11Z PH �CQJ��,