NCS01163_2023Permit_Initial

2023
Permit and Registration
Premium Tanks & Stone
is hereby issued a Septage Management Firm Permit,
ZNti STATE
Permit Number NCS-01163
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. City of Roxboro WWTP, Roxboro, NC
2. Septage Detention or Treatment Facility, SDTF-73-01
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
Date: 2023.02.23
Sugg 14:40:16-05'00'
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*
PREMIUM TANKS & STONE
The "Firm name" must be exactly as it is shown on your vehicle(s).
Septage Management Firm permit number (NCS #)
NCS-01163
Enter the five digits following the NCS #
Street address of office*
Street Address
120 BURCH AVE
Address Line 2
City
State / Province / Region
ROXBORO
NC
Postal / Zip Code
Country
27573
United States
County*
Person
Mailing address same as street address of office?*
Yes • No
Mailing Address*
Street Address
PO BOX 1037
Address Line 2
City
State / Province / Region
ROXBORO
North Carolina
Postal / Zip Code
Country
27573
United States
Phone* Fax
3365972005
Email*
[e-mail]
Owner Info
Firm owner's name*
KIPPY BLANKS
Mailing address same as street address of office?*
Yes 0 No

Mailing Address*
Street Address
PO BOX 1037
Address Line 2
city
ROXBORO
Postal / Zip Code
27573
State / Province / Region
NC
Country
United States
Phone* Fax
3365972005
Operator Info
Firm operator's name* Firm operator's title
KIPPY BLANKS PRESIDENT
Mailing address same as street address of office?*
• Yes No
Phone* Fax
3365972005
Type and amount of septage pumped in the last 12 months
Amount in gallons*
Domestic 0
Portable Toilet waste 40,000
Grease (Restaurant) 0
Treatment Plant 0
Industrial/Commercial 0
North Carolina counties of operation
List each county you plan to do business in:*
PERSON,CASWELL, DURHAM ORANGE
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*
12/15/2022
Title*
PRESIDENT
Choose how to add vehicle descriptions*
• Add vehicles individually Upload List
Pumper Vehicles
Usage* License Tag #* Vehicle Identification #* Tank Capacity*
Portable Toilet Waste JTE5316 3C7WRMBLODG518984 850
Portable Toilet Waste JTE5397 3C7WRMCL8JG391993 1,000
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no.
Approved wastewater treatment plant*
• Yes No
If yes, list the facilities below and upload or submit by mail a copy of Wastewater Treatment Authorization for each plant as indicated in
subparagraph .0833(c)(14) of the Septage Management Rules.
Mail forms to:
NC DEQ
Division of Waste Management - Solid Waste Section
1646 Mail Service Center
Raleigh, NC 27699-1646
Wasterwater Treatment Facility Name* Expiration Date* Authorization
ROXBORO WASTEWATER TREATMENT PLANT 12/31/2023 waste.jpeg 1.07MB
Septage Land Application Sites (SLAS)
Yes • No
Septage Detention or Treatment Facility (SDTF)
Yes • No
Other disposal method*
Yes • No
Septage Management Firm Operator Training Completed
Date* Hours*
12/3/2022 4
Location*
RALEIGH
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
11/16/2022
03:04:26 AM
Print Name* Title*
KIPPY BLANKS PRESIDENT

AUTHORIZATION TO DISCHARGE SEPTAGE T WASTEWATER TREATMENT FACILITY
Forth Caroiina Department f r. vironmental 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, Derek Clayton, ORC #9264 for the City of Roxboro VVVVfP
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
902 Cavel-Chub Lake Rd. Roxboro NC 27574 (NCO021024)
(Address)
3365998232 do hereby authorize Kippy Blanks
(Phone Number) (Owner/Operator of Septage Management Firm)
of NCS # 1163
(Septage Management Firm Name and NCS number)
to dispose of: domestic septage NO J portable toilet waste YES
grease septage (grease trap pumpings) NO commercial/industrial septage NO from
Person County NC (only!) Domestic Septage (Only!) -
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
Septic Dumping Station at the head of the Roxboro WVVfP located at 902 Gavel -Chub Lake Rd -
(Location)
between the hoUrs of S 30am-11 30am 8 1Z30prrt-6pm (]ate, by permission arsly)
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 _ c-�­".�=-- [� 7., Date fZ -9- .2¢2_221--
(Facility Op rator) ]
Subscribed and affirmed before me this _ �lr day of zp 22 -
My Commission expires:
(Notary Public) a
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Note: Falsification of this document by the septage management firm shall lead to perw,6'aca�it�p-
SJSalid_Waste/CLA/5EPTAGE/FaRM5/2018 Firm A pph cation/WWTP Authorization Form 20Is ►J `V
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