NCS00860_2023Permit_Initial

2023
Permit and Registration
Village of BHI Utilities Dept
is hereby issued a Septage Management Firm Permit,
sTArE� _ Permit Number NCS-00860
oand registered as a
NORTH
A%L 12 t
-�� 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. Bald Head Island WWTP, Bald Head Island, 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 Perry
Sugg
Digitally signed by Wm
Perry Sugg
Date: 2023.02.20
09:37:42-05'00'
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 27699-1
(1.) Firm name: (The "Firm name" must be exactlQy as it is shown on; your vehicle(s)).
Street address of office:
City: &AL &xQ
Mailing address (if different):
kA10A 6A- a
State: tip— Zip: 2- ?+Zk
0 . S wX
City:
L�a\�04 a&N
State: 0(-
Zip 2 '8�`
Phone:
auo - L- 5q-
Onm
Fax: 6 -0
E-Mail:
0Ec
County:
1 U Q 5 k
Septage Management
Firm permit number: NCS #
(2.) Firm owner's name: 4�
e
s `
Mailing address (if different):5t
P , qj�'-)c
City:
s
'\ \� �,
�
�
State: tUC-
Zip
Phone:
Ci 1) -- t k srl -
a✓%Db
Fax: -
4 S 9 - -7 3 5 3
(3.) Firm operator's
Mailing address (if different):Qd `�'
i
City: ` \Q" s` C.State: _Zip:
Phone: . ` , , VI S') - q-10� Fax:
Firm operator's title:
(4.) Type(s) of septage pumped: Write in the number of gallons gumged in last 12 months (Example: Domestic: 50,000).
Domestic
Toilet Waste Grease (Restaurant) Treatment Plant Industrial/Commercial
7 a© n a v
(5.) N.C. Counties of Operation: Jf"\s(')S." ,\C
(List each county you are authorized to do business in)
(6.) Total Number of Pumper Vehicles Operated: V.,e-
Number used for: Domestic Septage: Grease (restaurant):
Other: Portable Toilet Waste: X
Vehicle Information: (use additional paper if needed)
License Tag # Vehicle Identification # Tank Capacity
F6 i 25
i
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 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? (,k ) yes ( ) no
Initial �111-. Date
1,1,-- 5 2.o'Z"L
(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 Complled-
Date: q�> 6 1 2OZZ Location: ��fN NY-. Hours:
Training Sponsored or Provided by: N L
(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: �C _
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.
igna (Sign ture of companyofgcial required
kLahp m �Vl
Print Name
Other Comments:
J'J., 1 ,:� i Zo-L2-
Date
V )1q,
Title
PAGE 2
Rev. 0426-2021

NC SFP'TAGE MANAGEMENT FIRM
Recertification of Pumper Vehicle(s)
Septage Firm Permit#:_ NCS- C>68(oO
Number of Pumper Vehicles: 1
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 anomprisonment."
I2 2 �'-L
-2 aj�- Sign ure (Signature of com)kany off, a11 M_
l equired) Date
Print Name Title
SASolid_W'astelclalseptagelformsTumper 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 _ �r1�a.n 1-�ngsa p L--
(Plant Operator in espons' a Charge (ORC), ORC License Number, Name of Plant)
(Address) C
- sr.�S do hereby authorize
(Phone Number) (Owner/Operator of Septage Management Firm)
of ac.�\��P S -• NCS # �0
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage ___ ✓ portable toilet waste
grease septage (grease trap pumpings) — ©✓ commercial/industrial Septage _,from
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
P�:\yr"
�tt b N
(Location)
between the hours of co" �1C'�_.55�—`6`— v`�wa'e 4" -
Reintroducing partially treated liquid into a grease trap is acceptable Yes x No
This authorization shall be valid untie _ r S � 0 2'L
(Usually December 31, Year)
Signed~� Date Z 7--�—
(Facility Operator)
Subscribed and affirmed before me this71—,-__ day of G 20 o O
_ My Corn mission expires: �,� OQ�—
--- �#0
(Notary Public) , ���NP
04 FICIAL SEAL) s0.y's�
NOTARY
PUBLIC
Note: Falsification of this document by the Septage management firm shail lead to peN @f Vocation. ,�•
S:/5olid_Waste/CLA/SEPTAGE/FORMS/2015 Firm Application/WWTP Authorization Form 2018 ; /CK COO

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