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Home My WebLink AboutSDTF9210_RENEWAL_APPLICATION_2024APPLICATION FOR A PERMIT TO OPERATE A SEPTAGE DETENTION OR TREATMENT FACILITY North Carolina Department of Environmental Quality Division of Waste Management - Solid Waste Section 1646 Mail Service Center, Raleigh, NC 27699-1646 Operator and Facility Information 1. Applicant k KAM? i- &OM &A ► LC M P1r + tZW RV Sai�S Address 23 o S HWN I451 -tzNa N 0 2.15-Z11 Phone (q 10) -I"TZ - 2. Contact person for site operation (if different from applicant): N1AfzI EM 0l- WS0PJ Title or position 4FFICAC- Dr�lrc meATOZ Phone 9 f i 7I-31 S_ Address 23n05 'f 70 S. �cAST Z 3. Landowner S MASTER F tJ1> A1G--MLLLC Address 0501 Ic• PR SS DR. 5 -M [ Sco Sfl AZ. e55Z59 4. Site Location: County WAXE f State Road Number TO BogrgeSs -FAST Directions to site: :L-40 CAST To EK IT * 30( E-A5-r OtJ 1 30 2 MtLVS ON 1ZI614-r 5. Is the location on a permitted Septage Land Application Site? If yes, give the site permit number here: 6. Indicate whether project is: new renewal modification For a permit renewal or modification, indicate the existing permit number SvTF-g2-10 and the permit expiration date tS/20Z0 7. Attach written, notarized landowner authorization to operate a septage storage or treatment facility form signed by the landowner (if the permit applicant does not solely own the property). If a corporation owns the land use a corporate landowner authorization form. If Limited Liability Company owns. the land, use a limited liability company landowner authorization form. 8. Aerial photograph scale 1 inch = 400 feet with site property lines accurately located on the photograph must be enclosed (if 1 inch = 400 feet is not available, I inch = 660 feet may be substituted). 9. Vicinity map (county road map showing site location). 10. Land application site or wastewater treatment plant to be used after treatment or storage: FeIZA4iTTED t~IRM WILL PUMP TANKS (over) Facility Information: the following information shall be included with the application form. 1. Facility to be used for: Storage ✓ Treatment 2. Types of septage to be stored or treated: Domestic septage Grease Trap Pumpings Portable Toilet Waste Commercialllndustrial Septage 3. Types of treatment to be provided: pH Adjustment (lime stabilization) pJ%A Screening Other (attach explanation if other) A description of the proposed detention or treatment facility including the size, type, and number of structures to be used and how those structures will be constructed or installed (use additional 5. An explanation of how septage will be discharged into and remo ed from the facility (use additional paper to explain, if necessary): 1ZS V' W i DiSG E SMArt_L "tA.NKS -Pt izET-TLY i NTQ ;; eLow 5gApeT -rAIN -s v-LA- 3" 'DISC BE HC E . W S-rW tit~ RJ"A i C P Po ±mot F:t p-m 6. An explanation of how any leaks or spills at the facility will be cleaned and how odors will be controlled (use additional paper to explain, if necessary): ALL-1"A+Ja.A-V-F SEWVi &?,0U ND. AN ( 6FI L" 7RAT MA-4 OCCUR W I i.. — N I D I MM [Afr LY CLEAN "T rNI'GS W € L F3E 'PUMPED BY A ?,E�RM I- MEV FIRM 111, Certification I hereby certify that: 1. The information provided on this application is true, complete, and correct to the best of my knowledge, and 2. 1 have read and understand the N.C. Septage Management Rules. 3. 1 am aware of the potential consequences, including penalties and permit revocation, for failing to follow all applicable rules and the conditions of a Septage Detention or Treatment F cility permit. Signatu (Signatureof � nyolclalrequired) Date Print name Title Note: This application will not be accepted for review until all parts of the application are complete. S:Solid WastelclalseptageftrmMSDTF-Application & Authorization\SDTF Permit Application -Jan 2016.docx Rev 01-07-16 Limited Liability Company Landowner's Authorization to Operate a Septage Detention or Treatment Facility North Carolina Department of Environmental Quality Division of Waste Management - Solid Waste Section 1646 Mail Service Center, Raleigh, NC 27699-1646 1 hereby certify that the undersigned limited liability company, 10* N)AST a' i40E_t4 wns 1 .$_ acres of land IocatedZ300 V 1•-FW'� �Q 5. T NG and identified .1730834017_Deed _800kand page of recorded deed or tax map parcel) and that the limited liability company agrees to allow Holiday Kamper of Columbia LLC (SDTF permit applicant) to use said land for a septage detention or treatment facility for a period of fen yrs (length of time) beginning _4/12/2022 (give date), and that on behalf of the limited liability company, I have read the North Carolina Septage Management Rules'. STORE Master Funding II, LLC (name of limited liability company) further understands that no Septage may be stored or treated until the Division of Waste Management has issued a permit for a detention or treatment facility. The above described property is owned solely by the undersigned limited liability company, or jointly with (name all co -owners, or state none), Date: ►4 Rr1. 1 Z - Z- SrroizE MASTER F- JRDt M6 a "C. Limited Liability Company (Print Name) Signatur uthorized Member or Manager) Nodl-Oaft&a 1)Ar Z611A- -m AA &,,-) e,4 County Angela Donahoe Senior vice President Print Name and Title 1, Ch-UO A. PAMV , a Notary Public for said County and State do hereby certify that ,64d (name of authorized member or manager of limited liability company) personally appeared before me this day and, being first duly sworn, acknowledged that he (she) is a (the) 5 V. of5 4IbY vN 1 limited liability company, and that by authority duly given and as the act of the limited liability company, the foregoing instrument was signed in its name by its authorized5,ye_(member or-manago , and that the statements contained therein are true. Witness my hand and official seal, this the _ I Z day of _ lX1 L 20 z Notary Public My Commission expires: �� Sj UZ3 * 15A N.C. Admin. Code 13B Section .0800 (OFFICIAL SEAL) PAU A 8. PENNER NOTARY PUBLIC - ARIZONA MARICOPA COUNTY COMMISSION # 560870 MY COMMISSION EXPIRES APRIL 15, 2023 Rev. 01-07-16 APPLICATION FOR A PERMIT TO OPERATE A SEPTAGE MANAGEMENT FACILITY (NON -PUMPER - $200 FEE PER FACILITY) DIVISION OF WASTE MANAGEMENT - SOLID WASTE SECTION 1646 MAIL SERVICE CENTER, RALEIGH, NC 27699.1646 (1.) Facility name: 11D.LIDAI V kr,41 K9 Of C4LV ►'L iA L.I.0 P84 CA' L41"M , W VXW 12V SALES Street address of office 2 300 VS I4 W `I 7 0 SUSIN ES5 CAST &Ar7ZN We 215 -41 Mailing address (if different) spirm 0 County WAKE (2.) Facility owner's name CAM Pt IVY- Vj0RLD RV SArLIV 5 Mailing address 2300 05 +W%j 70 SU-4sWeSs MAST &ASM~"R K3C 215219 Phone: (q (al) "'I "12- S 1 SS Email: (3.) Facility operators name Mailing address Phone (4.) Type(s) of septage managed (check all that apply) Domestic Portable Toilet Waste (5) Treatment Plant Facility operators title IndustdallCommercial Facility Types: Check all that are applicable and provide the permit numbers. a) Septage land application site b) Boat pump -out storage c) Septage storage tanks d) Septage treatment e) Grease treatment Grease (restaurant) (6) Name and Permit Number of all permitted Septage Management Firms using facility: (1) (2) (3) (Use additional sheets if necessary) 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 try r are .7i al pAnalties for knowingly making a false statement, representation, or certification. Sign• tune' Date Print Name *Signature of company official required. S:Solid_Waste/CLPJseptage/forms12018 Firm Application/Non-Pumper-2018 Title