NCS01629_2024Permit_Initial

2024
Permit and Registration
K. Jones Porta Johns LLC
is hereby issued a Septage Management Firm Permit,
ZNti STATE
Permit Number NCS-01629
o and registered as a
e:,e D
NORTH
EQ
A%L 12. ��
-�� Septage Management Firm�� �� w� ��nffii�uty
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. Septage Land Application Site, SLAS-78-23
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 this registration expire on December 31, 2024.
Digitally signed by Wm Perry
Wm Perry S u g g Sugg
Date: 2024.04.15 09:10:25-04'00'
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*
K.Jones Porta John
The "Firm name" must be exactly as it is shown on your vehicle(s).
Septage Management Firm permit number (NCS #)*
NCS-01629
Please enter the complete NCS #, including the 5 end digits (NCS-XXXXX)
Street address of office*
Street Address
233 Swift Creek Rd
Address Line 2
City
Raeford
Postal / Zip Code
28376
County*
Hoke
Mailing address same as street address of office?*
Yes O No
Phone*
9105858624
Email *
[e-mail]
State / Province / Region
NC
Country
United States
Fax
Owner Info L^'
Firm owner's name*
Kimberly Hyz
Mailing address same as street address of office?*
Yes No
Phone* Fax
9105858624
Operator Info
Firm operator's name* Firm operator's title
Kimberly Hyz Owner
Mailing address same as street address of office?*
_, Yes U No
Phone* Fax
9105858624

Type and amount of septage pumped in the last 12 months ^
Amount in gallons*
Domestic 0
Portable Toilet Waste 10,000
Grease (Restaurant) 0
Treatment Plant 0
Industrial/Commercial 0
North Carolina counties of operation
List each county you plan to do business in:
Hoke
Cumberland
Robinson
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
ad4lzz��
Date *
10/6/2023
Title*
Chevy
Choose how to add vehicle descriptions*
0 Add vehicles individually 0 Upload List
Pumper Vehicles
Usage* License Tag #* Vehicle Identification #* Tank Capacity*
Portable Toilet ZR-5074 1GBIKUEY9HF216303 350
Waste
Septage Disposal Method
For each method, indicate whether you plan to use it by checking yes or no
Approved wastewater treatment plant*
Yes No

Septage Land Application Sites (SLAS)*
Yes No
If you are not the permit holder for the septage land application site, you must have a signed land application authorization form for each site.
Permit Verification
0 I certify that I AM the permit holder for this SLAS.
If unchecked, please attach a signed land application authorization form for each site.
SLAS #*
Expiration Date*
SLAS-7823 12/7/2025
Septage Detention or Treatment Facility (SDTF)
Yes No
Other disposal method*
Yes No
Septage Management Firm Operator Training Completed
Date * Hours*
1/27/2024 4
Location *
Gaston county
Training Sponsored or Provided by*
NC Septic Tank Association
Septage Land Application Site Operator Training Completed
Date Hours
0
Location
Training Sponsored or Provided by
Registration Type
Select one*
* Registered Portable Sanitation Firm
0 Registered Septage Management Firm
0 Registered Portable Sanitation and Septage Management Firm
Comments and Notes^
Comments or notes
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.

Signature
Date
10/6/2023
04:29:54 PM
Print Name*
Kimberly hyz
Title*
Owner

AUTHORIZA710N TO DISCHARGE SEPTAGE A T A SEPT G E LA --ND APPLICATION
SITE PERN.ITTEC� TO S-0mEC�t�E OTHER THAN YOU RSE�,�
(This form is used bya Iand application site permit balder to indicate that pertT)i-v,,,)sion- hay been
given to a permitted Septage Management Finn to Iand apply Sept�g� c)n tt�� perrinipt ers,,
land application site.)
All• ti ' � �,+1a5�`� : Y ■ �# � 4r i+FF+ t .r � ## fib'' �'�F�
(501te Operator)
40
400
F} #ap
44- pwc—iL�.k)h;pdw� (Operat-or Address)
cio ereby
iz 1.
� •ice.
■- � ,�� �. sa�4�I■�To�i+ + r.Y■t . ffV # ■#;■ f~a a+„ ■.. &,W* f %%J W.riaif ■ =—Y�}M rr�+i''M lfrL`r. r . W% bf F sr,■MVp-1 • A. i-+` +.■' s . ■w++ .-- �,.+-■ 4- +/�#' ■■,•■ram*
Firrn)
(Owner of Septag,e
Managem nt
Poo
NCS
& ooffw -101r,01'
(Name of Septage Management Firm .10pol
Jr' } - { -r �YiiEr
d � � re � nor SFr ■.
T-•�4 k �� ` +Y �I�f•S T F v'J L 7 I���ly {■*��i%y } ■ } y i# �7�y..}�4• • • : L
..ai,.,�� .r.■r �■ 'r a o+� ■ o- ■ r r+ai-��� W+.�. tea•
e tage Mana ement Firm Address)
t>%..
to use septage disposal site #I-�� ,for the disposal of„ C? gallons of septage* in 20.,
Da t e
* igned
* f
ti t �,.+.� �-. +ter k•+-+ �■'ti .tii .:c a ti.-•-�.rr��.l ■ �tK,l� ■-tip ,� *v ■••..�.�r■ 3+ • L
te 0 erator
defined in G.S. 130-A-29U(aj{�Z}. The site will be operated i1i accordance with 15A N(,,.AC 13B
.08OO - Septage Management Rules
Return the properly completed for tag
North Carolina Department of Environmental QUality
Di'4L
vision o Management
Waste Section
16!�5 Mail Service Center
Raleig NC 27699wrl646
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