SDTF-10-22_RENEWAL_APPLICATION_2024

APPLICATION FOR A PERMIT TO OPERATE A SEPTAGE DETENTION OR
Operator and Fa(
1. Applicant
Address
Phone
2. Contact persi
Title or positii
Address
3. Landowner
Address
4. Site Location
Directions to site:
TREATMENT FACILITY
North Carolina Department of Environmental Quality
Division of Waste Management — Solid Waste Section
1646 Mail Service Center, Raleigh, NC ; 27699-1646
;ilit Infor
ation
(.uD '*of
Alt
)n for site
)n
operation (if different from applicant): _ C, oNtle5 `{oL
Phone cxt— Qta 3 a16�
�L
Cou
ty 6f3State Road Number
5. Is the location on a permitted Septage Land Application Site? N o
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 number5pTg- In-o.2 and the
permit expiration date 03 1
7. Attach written, notarizec 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 1a d, use a limited liability company landowner authorization form.
S. Aerial photograph scale 1 inch = 400 feet with site property lines accurately located on the photograph
must be enclosed (if 1 hch = 400 feet is not available,1 inch = 660 feet may be substituted).
9. Vicinity map (county
10. Land application site
(over) 0
map showing site location).
wastewater treatment plant to be used after treatment or storage:
IkanuYa" 6rrn .

Note:
acility Information: the fo
owing information shall be included with the application form.
Facility to be used for:
Storage .: ` _ Treatment
Types of septage to be
stored or treated:
Domestic
Portable
Septage rease Trap Pumpings
Toilet Waste Commercial/Industrial Septage
Types of treatment to
SeQ- Qka
be provided: pH Adjustment (lime stabilization)
Screening Other ( (attach explanation if other
-
A description of the p
posed 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
paper to explain, if ne
essary):
An explanation of how
additional paper toe
septage will be discharged into and removed from the facility (use
plain, if necessary):
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):
artification
I hereby certify that:
1. The informatio
knowledge, and
i provided on this application is true, complete, and correct to the best of my
2. 1 have read an
3. 1 am aware of i
J understand the N.C. Septage Management Rules.
he potential consequences, including penalties and permit revocation, for
failing to folio
all applicable rules and the conditions of a Septage Detention or Treatment
li pe t.
/1
a�
nyofficialre ired) Date
?Y*-'5i
Title
Signatur gn ureof
l
Print name
'his application will not be a
cepted for review until all parts of the application are complete.
word tr
a owv.av --- r-„ppiicanon a HutnorizatiomsDTF Permit Application -Jan 2o16.docx
Rev 01-07-16

SDTF Renewal Supple
3. For temporary storage
4. One 1500 gallon steel to
authorized 3rd party pumpe
contents.
I. Industry standard 2 inch
3rd party pumper truck will
6. In the unlikely event of a I
spread to control odors. The
ry response page:
transported to another permitted facility,
will temporarily store portable toilet septage, when the tank is full,an
'uck will be contracted to empty this tank and properly dispose of the
yes will transport septage from permitted trucks to the tank. Periodically., a
PtY the tank as needed.
R, spilled septage will be contained and removed. Hydrated time will
nk is locked with a "No TRESPASSING" sign. It is monitored dail , be
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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
I hereby certify that the undersigned limited liability oompaQ n n "t—c— . owns
✓-✓ acres of land located 27. rn6 O mn 1 t, cc and identified
by ) S Z-noo ci 405 (book and p ge of ead deed or tax map parcel)
and that the limited liability company agrees to allow ` r... ✓„". U48DTF permit
applicant) to use said land for a septage detention or treatment facility for a period of cars (length
of time) beginning 13 Mwct, 2o'L$ (give date), and that on behalf of the limited liabili company, I
have read the North Carolina Septage Management Rules'. McFeA. -Q^, I—L. G (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).
Dater � f
Limited Liability Company (Print Name)
Signature (Authorized KffbO or ana Print Name and Title
orth Carolina
County
I,OonIN R P LOA)&- . a Notary Public for said County and State do hereby certify that
Tereec Ana M&,CA lb (name of authorized member or manager of limited liability company)
personally appeared before me this day and, being first duly swum, acknowledged that he (she) is a (the)
lY1Gnr (member or manager) of A1�Fo.rawN LLC- . the foregoing
limited liability
company, and that by authority duly given and as the act of the limited liability company, foregoing
a
instrument was signed in its name by its authorized f1• ana0tr (member or manager) , and that the
s lements contained therein are true. Witness my hand and official seal, this the 161 � day of
,2 N
,�I111t111IIIIIP,+,
i
Notary Public (0 n 1•��?
My Commissionexpireja-a12y i
b
blp !me•
* 16A N.C. Admin. Code 13B Section .0800 ; O; .,- 1
Rev. 01-07-1e

Limited Liability
I hereby certify that the unden
i, acres of end Iocatec
by 19 2-6ao 3 `f0
and that the limited liability co+
applicant) to use said land for
of time) beginning f
have read the North Carolina
limited liability company) fwth
Waste Management has issut
is owned solely by the unders
-f -\'T-C C
Limited Liability
Signature
ONNA r La
personally appeared before
k _. --(M
company, add that by autho
instrument was signed In its
sp,tements contained theWl,
ec.ec-, b•er_. 492--:
Notary Public
My Commission
* 15A N.C. Admin. Code 13B
►mpany Landommees Authorization to Operate a
.ge Detention or Treatment Facility
Carolina Department of Environmental Quality
n of Waste Management - Solid Waste Section
Marl Service Center, Raleigh, NC 27699-1646
fined limited liability pang "N' Inn Z , L C: owns
z2oo o c-e and identified
( k and page of rkbr6d deed ortax map parcel)
ipany agrees to all yo,rk%, 'j, tc 3e re, res G tom. (SDTF permit
i septage detention or treatment facility for a period of' 6ne- r ec r (length
' z 2- (give date), and that on behalf of the limited Icompany, I
eptage Management Rules*. ram`- Ik 1-L-12-- (name of
r understands that no septage may be stoned or treated until the Division of
t a permit for a detention or treatment facility. The above described property
ined limited liability company, or jointly with
(name all co -owners, or state none).
2-3
L0—
r (Print Name)
Print Name and Title
, a Notary Public for said County and State do hereby certify that
(name of a thortmd member or manager of limited liability company)
this day and, being first duly sworn, ado w wedged that he (she) is a (the)
Mr or manager) of (W «- 4 „- n ; - t e-- , a limited liability
duty given and as the act of the limited liability company, the foregoing
ne by its authorized a e r (member or manager) , and that the
-a true. Witness my hand and offidal seal, this the day of
P C -"A
— _-- — (CFFICAUK)TARy
.N .
PtJBLyC'••..�
Rev. 01-07-16