NCS01708_2023Permit_Initial

2023
Permit and Registration
Carolina Moon Outhouses
is hereby issued a Septage Management Firm Permit,
STATE,,
Permit Number NCS-01708
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 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 Perry Digitallysigned by
Wm Perry Sugg
Sugg 114:54:27— 9
04'00
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 exacdvas it is shown on your vehicle(s).
Carolina Moon Outhouses
Street address of office:410 Camp Kirkwood Rd.
City: Watha State: NC
P.0 Box 295
Zip28478
E-Mail: 993
Countypender . Septage Management Firm permit number: NCS # 0
(2.) Firm owners name:Zachary Grizzle
Mailing address (if different): 410 Camp Kirkwood Rd.
City: Watha
Phone: [phone]
Mailing address (if different):
Citv: Willard
Phone: [phone]
State: NC Zip: 28478
Fax:
carolinarnovnouthouses@ mail com
(3.) Finn operator's name:Zachary Grizzle
State: NC Zip: 28478
Fax:
Mailing address (if different): 410 Camp Kirkwood Rd.
City: Watha State: NC
Phone: [phone] Fax:
Firm operator's title: Owner
Zip28478
(4.) Type(s) of septage pumped: Write in the number of gallons pumped in 201$ (Example: Domestic: 50,000).
Domestic
Portable Toilet Waste
Grease (Restaurant)
Treatment Plant
Industrial/Commercial
[0 10
0
P
10
(5.) N.C. Counties of Operation: Pender, New Hanover, Bruswick, Duplin, and Sampson
(List each county you 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
1
DB59489
4M9BBGD23KC102025
400 GAL (Restroom Trailer
2
3
4
5
APPLICATION CONTINUED ON PAGE 2
zui
6 a

APPLICATION FOR PERMIT TO OPERATE A SEPTAGE MANAGEMENT FIRM
(CONTINUED FROM PAGE 1)
(7.) Septage Disposal Method: (check one)
a) Approved wastewater treatment plant: (� yes04)
no. If yes, submit Wastewater Treatment Authorization
for each plant, as indicated in Subparagra .083 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:
(8.) Septage Management Firm Operator Training Completed:
Date: �e"IJ jZ " &2O.1S Location:
Training Sponsored or Provided by:
(9.) 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:
Certification Statement
Hours:
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.
Y�l �--t7fz - -
Signature (S' tuneofcompan iairequired)
Zachary P Grizzle
Print Name
8/15/2023
Date
Owner / Operator
Title
Other Comments:
This application is for new operator for a portable restroom trailer.
Contracted with Register's Septic Tank Pumping [phone] Turkey, NC
Contracted with Skippers Septic Pumping [phone] Wilmington, NC
S:/Solid Waste:/CLAISEPTAGEIFORMS/2016 Fum App1icatiDiVRmPemritAppkatior016
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