NCS00900_2023Permit_Initial

2023
Permit and Registration
Lake Gaston Campground
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-00900
o and registered as a
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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. On -Site Wastewater Disposal System (Lake Gaston Campground)
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 115:04:55— 2 05 00'
Perry Sugg, Environmental Compliance Branch Head

For questions regarding this form or the online application process, please contact Jeffrey Bullard (919-707-8285) or Chester Cobb (919-707-
8283).
Firm Info
Firm name*
Lake Gaston RV Resort
The "Firm name" must be exactly as it is shown on your vehicle(s).
Septage Management Firm permit number (NCS #)
NCS-00900
Enter the five digits following the NCS #
Street address of office*
Street Address
561 Fleming Dairy Road
Address Line 2
City
State / Province / Region
Littleton
NC
Postal / Zip Code
Country
27850
USA
County*
Warren
Mailing address same as street address of office?*
• Yes No
Phone*
Fax
252-586-4121 x3
Email*
[e-mail]
Owner Info
Firm owner's name*
MHC Lake Gaston LP
Mailing address same as street address of office?*
Yes • No
Mailing Address*
Street Address
2 N Riverside Plaza
Address Line 2
Suite 800
city
Chicago
Postal / Zip Code
60606
State / Province / Region
IL
Country
USA

Phone* Fax
252-586-4121 x3
Operator Info
Firm operator's name*
James Kaetzel
Mailing address same as street address of office?*
• Yes No
Phone*
252-586-4121 x3
Firm operator's title
Maintenance Supervisor
Fax
Type and amount of septage pumped in the last 12 months
Amount in gallons*
Domestic
0
Portable Toilet Waste
1 19, 998
Grease (Restaurant)
0
Treatment Plant
0
Industrial/Commercial
0
North Carolina counties of operation
List each county you plan to do business in:
Warren
Vehicle Info
Do you plan to operate pumper vehicles?*
• Yes No
"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 significant penalties for false certification including the possibility of fine and imprisonment."
Signature
Date *
12/7/2022
Title*
Community Manager
Choose how to add vehicle descriptions*
• Add vehicles individually Upload List
Pumper Vehicles

Usage* License Tag #* Vehicle Identification #* Tank Capacity*
Portable Toilet Waste n/a Off Road Tractor 350
Portable Toilet Waste n/a Off Road Tractor 500
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Approved wastewater treatment plant*
Yes • No
Septage Land Application Sites (SLAS)
Yes • No
Septage Detention or Treatment Facility (SDTF)
Yes • No
Other disposal method*
• Yes No
Description * Authorization
On site in Lake Gaston Campground State Approved
Septic System
Septage Management Firm Operator Training Completed ^
Date* Hours*
2/19/2022 4
Location*
Raleigh, NC
Training Sponsored or Provided by*
NC Pumper Group & NC Portable Toilet Group
Septage Land Application Site Operator Training Completed
Date Hours
0
Location
Training Sponsored or Provided by
Registration Type^
Select one*
Registered Portable Sanitation Firm
• Registered Septage Management Firm
Registered Portable Sanitation and Septage Management Firm
Comments and Notes

Comments or notes
Certif cation 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
Date
12/7/2022
11:25:00 AM
Print Name*
Jennifer Hamby
Title*
Community Manager