NCS01382_2023Permit_Initial

2023
Permit and Registration
Albemarle Rent -A Jon
is hereby issued a Septage Management Firm Permit,
ZNti STATE ,, Permit Number NCS-01382
oand registered as a e:,e D
NORTH CAROUNA
EQ�J
%L 12. �
-�� Septage Management Firm awnen� f� wrnmenta�lty
9
E,%r Q'M
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. Elizabeth City WWTP, Elizabeth City, 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 Digitallysigned by
Wm Perry Sugg
Sugg 1/2282020 007
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 27699-1646
(1.) Firm name: (The "Firm name" must be exactly as it is shown on your vehicle(s)).
t i - - Jon
Street address of office: 20J CharS-i
City: E ' State: 0C --Zip: 21903
Mailing address (if different): fb Sox 2q F7
City: State: lG Zip
Phone. 252- 3 - I tol Fax:
E-Mail: y► tn+ ry ,
County: Imo' Septage Management Firm permit number: NCS # 0138Z
(2.) Firm owners name: MC Ph rSbn En VY12 ties
�lwMbina '� �! rcric4tiw� inG.
Mailing address (if different): s ,rvt -
City:
State:
Phone: I-ax:
(3.) Firm operator's name: Sm Kc ?V% n Firm operator's title: Sest
Mailing address (if different): MP —
City:
State: Zi
Phone: 252 `5G2-'* U50S Fax:
(4.) Type(s) of septage pumped: Write in the number of gallons oumned in last 12 months (Example: Domestic: 50,000).
Domestic Portable Toilet Waste Grease (Restaurant) Treatment Plant Industrial/Commerci,
12 l0'10
(5.) N.C. Counties of Operation: Ac . C%rrilue Camden IsoL a%lftk, A.4a W444AS
-
(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: _
Vehicle Information: (use additional paper if needed)
License Taq # I Vehicle
aA
Tank Capacity
APPLICATION CONTINUED ON PAGE 2
PAGE

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
(CONTINUED FROM PAGE 1)
(7.) Do you plan to operate pumper vehicles? (check one) (X) 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— P �' --Date // Wit) 22
(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 FirIn Operator Training Completed:
Date: Location: Neo , nt. NC Hours: io
Training Sponsored or Provided by: NC ar4AbI c 77w tg - Grw.�D
(10.) Septage Land Application Site Operator Training Completed:
Date: Location: Hours:
Training Sponsored or Provided by:
(11.) Registration type requested: CHECK ONE
Registered Portable Sanitation Firm: �4
Registered Septage Management Firm:
Registered Portable Sanitation and Septage Management Firm:
Certification 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.
= �r
Si at a (Signature of companyofficial required)
J�1///0/! L L
Print��
Other Comments:
Date
Title
11/3o I_70 2-?—
PAGE 2
Rev. 04-26-2021

NC SJjPTAGE MANAGEMENT PI R Y
Recertification of Pumper Vehicle(s)
Septage Firm Permit #: NCS- Z
Number of Pumper Vehicles: 3
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."
Si ature (Signature of company official required)
f
Print Name
A0 12- 0 22-
Date
Title
RECEIVED
DEC j 4 NZ
sOUD WASTE SECTION
S:lSolid WastelclalseptagelformslPumper Vehicles Cetification.doc

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.
(Plant Operator in Responsible Charge (ORC), ORC License Number, Name of Plant)
�-6) = 'IVA) 9
(Address) if
c;,'59.3 do hereby authorize �'rc_�hGIS7
(Phone Number) (Owner/Operator of Septage Management Firm)
of
N
(Septage Manageme4 Firm Name andACS number) kA f A
to dispose of: domestic septage ✓ portable toilet waste
greanse septage (grease trap pumpings) commercial/industrial septage from
ra.54- Ao{A &cro f i yt.0-
(County or other Geographic Area)
at the above named wastewater treatment facility. Septage shall be discharged at:
7SD o 5 Crf ifr 6 '1 Sj 4 OC- 7 a
(Location)
between the hours of ob
-
Reintroducing partially treated liquid into a grease trap is acceptable Yes No
This authorization shall be valid until �taC E' ✓�-� ~Pf 3` ��
(Usually December 31, Year)
Signed Date (;2-57-da
(Facility Operator)
Subs be jI AAA
nd affirme before me this day of 20
My Commission expires:
(Notary ublic)
(OFFICIAL SEAL)
Note: Falsification of this document by the septage management firm shall lead to permit revocation.
5:/Solid_Waste/CLA/SEPTAGE/FORMS/2018 Firm Application/WWTP Authorization Form 2018

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