NCS00913_2023Permit_Initial

2023
Permit and Registration
Randy Miller & Sons Septic Tank Service
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-00913
o and registered as a
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NORTH
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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. Cooleemee WWTP, Woodleaf, 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 111:40:23— 053
00
Perry Sugg, Environmental Compliance Branch Head

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
0
DIVISION OF WASTE MANAGEMENT - SOLID WASTE SECTION —1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646
(1.) Firm me: (The "Firm name" must be
P,q Y\j
, I I Y Y
Street address of office:
City: 4,6) i
Mailing address (if different):
Phone:
County:
(2.) Firm owner's name:
Mailing address (if different):
as it is shown on your vehigWs)). q
yap S o`' q_ cis. c S-ff
State: N e. Zip: 21ti2 cd
State: Zip.
Fax:
M Septage Management Firm permit number. NCS #
t 11 1
City: State: Zip
Phone:3 3 4, °P 9 3 21v I Fax:
(3.) Firm operator's name: 0'YA c k" f�I1 Y' Firm operator's title: 0 W I*y-
Mailing address (if different):
City:
State: Zip:
Phone: Fax:
(4.) Type(s) of septage pumped: Write in the number of aallons pumped in last 12 months (Example: Domestic: 50,000).
Domestic
Portable Toilet Waste Grease (Restaurant)
Treatment Plant in ustriallCommercial
ZS c
(5.) N.C. Counties of Operation: U t Iw WQ1N �v s cq ,_�N
(List each county you are authorized to do business in)
(6.) 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 #
Vehicle Identification #
Tank Capacity
A T1006-
IM mn Ob A63psol 04
-Sob
2
3
4
5
APPLICATION CONTINUED ON PAGE 2

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? ( )_yes ( ) no InitialP,4�M Date
(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 Comp teed: Date: ;- Location: FNI &rL4 Hours:
Training Sponsored or Provided by: C 5 rA
(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.
0 wnPr (1�23•Z2
afure of companyofcial required) Date
Title
Other Comments:
PAGE 2
Rev. 04-26-2021

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.`
Y 99 90 ` ('lit' 1.e�
(PI nt Operator in Responsible Charge (ORQ, ORC license Number, Name of Plant)
)61 d lei* G
i (Address)
A A -
_do hereby authorize ��� Ile V-
Owner O erator Se Management Firm
Phone Number) ( / t�l� g )
�, T s ��
Of M NCS # 3
(SeptageMan%agement Firm Name and NCS number)
to dispose of: domestic septage portable toilet waste
grease septage (grease trap pumpings)
•� � � t `�.Y"�.�4� LPL` +�� � S��
tt (/: r-
septage T , from
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
It &Lt-�
(Location)
between the hours of e� on 7
Reintroducing partially treated liquid into a grease trap is acceptable Yes �nlo
This authorization shall be valid until caw r' v, ;9- d -x.3
(Usually December 31, Year) -
Signed L4L,1A
(Facility Operator)
Subsc and affrr d before a his �` 3IV
ifr
Date /I—A.3 - J-7--
day of K OWA�-eC, 20 oZ-
My Commission expires: /-t0 , 9c:,'` 2112
(Notary Public)
STACEE S DALTON
Notary Public, North Carolina y Davie County (OFFICIAL SEAL)
My Commission Expires
August 25. 2024
Note: Falsification of this document by the septage management firm shall lead to permit revocation.
s:/soiicl watWo.A/sEPTAGE/FORMS/2016 Rrm AppUcation/W WTP Authorization Form 2016

North Carolina Department of Environmental Quality
Division of Waste Management INVOICE
Solid Waste Section
Division of Waste Management To: Randy Miller
Solid Waste Section Randy Miller & Sons Septic Tank Service
1646 Mail Service Center 295 Miller Road
Raleigh, NC 27699-1646 Mocksville, NC 27028
Phone/Fax: [phone]
Email: jared.wilson@ncdenr_gov PAID
CK. Na Z �:Sr Date: 09/27/2022
DATE ZI- �~n Invoice #: NCS-0U913-2023
Septage - Annual:
Randy Miller & Sons Septic Tank Service (NCS-00913)
295 Miller Road $550.00
Mocksville, NC 27028
Number of Trucks: 1
Date Due: 12/15/2022
LATE PEE$: in accoroar.ce w4Yi NC C-P"ra1 Sialutes GS 13134,-291 1WZ, a late fee will be applied to arsy an wv pofmit lees not suhnibed by lan_:.:
Payment Options:
E-check Available online at httpsdit-nc.aov/swnay
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 h s del! ne oov%4wnav
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.
rConvenience Fee of 2.6S% 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 checks.]
Expjanation 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 regarding:
Billing Jared Wilson [phone]
Regulations or Technical Assistance Chester Cobb [phone]
Jeffrey Bullard [phone]
More information available on the web•
North Carolina Department of Environmental Quality (DEQ) - httWY/deq ncT
North Carolina Sold Waste Program - httos%1/ ,eecinc goy/about/divisions/waste-managMent/soNd writ section
North Carolina Septage Management Program - https //dgq_r oov/about/divisions/waste-manaoemenVsolid waste section/snecia! wastes and aiternative-
handing/sepWe