NCS01676_2023Permit_Initial

2023
Permit and Registration
Carolina Restroom
is hereby issued a Septage Management Firm Permit,
�szArr of
Permit Number NCS-01676
o and registered as a e D
-�= Septage Management Firm Department fE w� nmentalQulity
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 not authorized to transport septage or discharge septage in the State of North Carolina. Only septage management firms permitted to transport and
discharge septage shall be contracted to remove wastewater from the portable restrooms.
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
2023.04
Sugg 14:021-0400 20
Perry Sugg, Environmental Compliance Branch Head

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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).
Carolina Restroom
Street address of office:1163 Shoreside Way
City: Mount Pleasant State: SC
Mailing address (if different): PO Box 424
City: Sullivans Island
Zip:29464
State: SC Zip: 29482
Phone: [phone] Fax:
E-Mail: brian@carol in arestroom.com
County:Charleston
(2.) Firm owner's name: Brian Holladay
Mailing address (if different):
City:
Phone: [phone]
(3.) Firm operator's name: Brian Holladay
Mailing address (if different):
City:
Septage Management Firm permit number: NCS # qb
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State: Zip:
Fax:
Firm operator's title: Owner
State: Zip:
Phone: Fax:
(4.) Type(s) of septage pumped: Write in the number of gallons pumped in 2015 (Example: Domestic: 50,000).
Domestic , Portable Toilet Waste I Grease (Restaurant) Treatment Plant Industrial/Commercial
I Restroom Trailers
(5.) N.C. Counties of Operation:
(List each county you do business in)
(6.) Total Number of Pumper Vehicles Operated: 0
Number used for: Domestic Septage:
Other:
Vehicle Information: (use additional paper if needed)
Grease (restaurant):
Portable Toilet Waster
License Tag #
Vehicle Identification #
Tank Ca aci
1
2
3
4
5
APPLICATION CONTINUED ON PAGE 2
PAGE 1

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
(CONTINUED FROM PAGE 1)
Toilets to be emptied by other firm permitted to transport and dispose of septage.
(7.) Septage Disposal Method: (check one) JRB 4/20/2023
a) Approved wastewater treatment plant: yesPC4)
no. If yes, submit Wastewater Treatment Authorization
NA
for each plant, as indicated in Subparagrappp .0833 of the Septage 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:_
Septage Management Firm Operator Training Completed:
Date: 03/09/23 Location: Online Hours: 6
Training Sponsored or Provided by: Jeffery Bullard
Septage Land Application Site Operator Training Completed:
Date: Location:
Training Sponsored or Provided by:
(10.) Registration type requested: CHECK ON
Registered Portable Sanitation Firm: ✓
Registered Septage Management Firm:
Registered Portable Sanitation and Septage Management Firm: 1
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.
03/09/23
ignature (Signature ofcompa " rcia required) Date
Brian Holladay
Print Name
Owner
Title
Other Comments:
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SJSolid_Waste:/CLA/SEPTAGE/FORMS/2016 Firm Application/FirmParm!tApplication20l6
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