SDTF3618 Application

APPLICATION FOR A PERMIT TO OPERATE A SEPTAGE MANAGEMENT FACILITY
(NON -PUMPER - $200 FEE PER FACILITY)
(1.) Facility name: N.
U`
DIVISION OF WASTE MANAGEMENT - SOLID WASTE SECTION
1646 MAIL SERVICE CENTER, RALEIGH, NC 27699-1646
A iI r
W
Street address of office
e l� 1
Mailing address (if different)
County 6 ('
(2.) Faciiity owners
Mailing address
Phone: A p —
(3.) Facility operator's name_
Mailing address Zo
Facility operators title
Phone S Email bft l L j s &(( A,14�a(145 .
(4.) Type(s) of septage managed (check all that apply)
Domestic Portable Toilet Waste Grease (restaurant)
Treatment Plant Industrial/Commercial
(5) Facility Types: Check all that are applicable and pro v' a the i numb rs.
a) Septage land application site
b) Boat pump -out storage
c) Septage storage tanks
d) Septage treatment
e) Grease treatment
(6) Name and Permit Number of all permitted Septage Management Firms using facility:
(1)
(2)
(3)
(Use additional sheets if necessary)
Certification Statement IL
I certify that the information and representations in this application for a permit are true, complete, and accurate
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 ItWJ ze are crim' I enalties for knowingly making a false statement, representation, or certification.
t*!tut Date
Print Name Title
*Signature of company official required.
S:Solid_Waste/CLA/septage/forms/2018 Firm Application/Non-Pumper-2018
Q)
=:a

APPLICATION 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 L2 t
Address MAL A6 (
Phone
Contact person for site
Title or position
Address LL
3. Landowner
Address
n (if different from applicant): Q f I� l I 4
Phone 7 "
4. Site Location: County State Road Number
Directions to site:
5. Is the location on a permitted Septage Land Application Site? a
If yes, give the site permit number here: Y
6. Indicate whether project is: new renewal modification
For a permit renewal or modification, indicate the existing permit number and the
permit expiration date
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, 1 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:
be4twW � v kid(- Ii
(over)

Facility Information: the following information shall be included with the application form.
1. Facility to be used for: Storage ,V/ Treatment
2. Types of septage to be stored or treated:
Domestic Septage rease Trap Pumpings
Portable Toilet Waste Commercial/Industrial Septage
3. Types of treatment to be provided: pH Adjustment (lime stabilization)
Screening Other (attach explanation if other)
4. A description of the proposed detention or treatment facility including the size, type, and number of
structures to be used and how those structures ill be con tructed or gstallipd (use ad itio al
paper to explain, if necessary): 4 f
5. An explanation of how septage will be discharged into and removed from th fa ility (use
a ditional paper to xplain, if necessary): V
i
6. An explanation of how any leaks or spills at the facility will be cle ned d ow odors will be
control) d ( se ad itional pert explain, if necessary):
III. 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
Faci ' ermit.
o - Zi
Signature (Sig ofco any official required) Date
Print name Title
Note: This application will not be accepted for review until all parts of the application are complete.
S:Solid Waste\cla\septage\forms\SDTF-Application & Authorization\SDTF Permit Application -Jan 2016.docx
Rev 01-07-16