WQ0003796_Residual Annual Report 2020_20210301

Initial Review
Reviewer Thornburg, Nathaniel
Is this submittal an application? (Excluding additional information.)*
r Yes r No
If not an application what is the submittal type?* r Annual Report
r Residual Annual Report
r Additional Information
r Other
Annual Report Year* 2020
Permit Number (IR)* W00003796
Applicant/Permittee Town of Dobson
Email Notifications
Does this need review by the hydrogeologist?* 0 Yes r No
Regional Office Winston-Salem
CO Reviewer
Admin Reviewer

Submittal Form
Project Contact Information
Rease provide inforration on the person to be contacted by N B Staff
Name * Michael FraDer
Email Address*
[e-mail]
electronic subnittal, confirmation of receipt, and other correspondence.
Project Information
........ ......... ....................................................................................................................................... .
Application/Document Type* r New (Fee Req ui red)
r Modification - Major (Fee Required)
r Renewal with Major Modification (Fee
Required)
r Annual Report
r Additional Information
r Other
Phone Number*
336-712-6418
O Modification - Minor
C Renewal
C GW-59, NDMR, NDMLR, NDAR-1,
NDAR-2
r Residual Annual Report
r Change of Ownership
We no longer accept these monitoring reports through this portal. Please click on the link below and it will take you to the correct form.
https://edocs.deq.nc.gov/Forms/NonDischarge_Monitoring_Report
Permit Type:* r Wastewater Irrigation r High -Rate Infiltration
r Other Wastewater r Reclaimed Water
r Closed -Loop Recycle r Residuals
r Single -Family Residence Wastewater r Other
Irrigation
Permit Number:* W00003796
Fbs Current Existing permt number
Applicant/Permittee Address* 307 N Main Street Dobson, NC 27017
Facility Name * Town of Dobson RLAP
Please provide comments/notes on your current submittal below.
At this time, paper copies are no longer required. If you have any questions about what is required, please contact Nathaniel Thornburg
at [e-mail].
Please attach all information required or requested for this submittal to be reviewed here.*
(Application Form Engineering Rans, Specifications, Calculations, Bc.)
Annual Land Application Report 2020.pdf 98.41KB
Upload only 1 RFdocurrent (less than 250 \B). Miltiple documents rust be contained into one RJFfile unless file is larger than
upload limit.
* V By checking this box, I acknowledge that I understand the application will not be
accepted for pre -review until the fee (if required) has been received by the Non -
Discharge Branch. Application fees must be submitted by check or money order
and made payable to the North Carolina Department of Environmental Quality
(NCDEQ). I also confirm that the uploaded document is a single PDF with all parts
of the application in correct order (as specified by the application).
Mail payment to:
NCDEQ — Division of Water Resources
Attn: Non -Discharge Branch
1617 Mail Service Center
Raleigh, NC 27699-1617
Signature
01VK101WV6._11�
Submission Date 3/1/2021

ANNUAL LAND APPLICATION CERTIFICATION FORM
WQ Permit#: WQ0003796 County: Surry Year:
Facility Name (as shown on permit):
Land Application Operator:
US Blosolids. Inc.
Town of Dobson
2020
Phone: [phone]
Land application of residuals as allowed by the permit occurred during the past calendar year?
❑ Yes Q No - If No, skip Part A, and Part B and proceed to Part C. Also, If residuals were
generated but not land applied, please attach an explanation on how the residuals were handled.
Part A - Residuals Application Summary:
Total number of application fields in thepermit-1
Total number of fields utilized for land application during the year:
Total amount of dry tons applied daring the year for all application sites:
Total number of acres utilizes for land application during the year:
Part B _ Annual Compiance Statement:
Facility was compliant during calendar year 20Z0 with all conditions of the land application permit
(including but not limited to items 1-13 below) issued by the Division of Water Resources. ❑ Yes ❑ No
If no please, provide a written description why the facility was not compliant, the dates, and explain corrective action
taken.
1) Only residuals approved for this permit were applied to the permitted sites,
2) Soil pH was adjusted as specified in the permit and lime was applied (if needed) to achieve a soil pH of at least 6.0 or
the limit specified in the permit.
3) Annual soils analysis were performed on each site receiving residuals during the past calendar year and three (3) copies
of laboratory results are attached.
4) Annual TCLP analysis (if required) was performed and three (3) copies of certified laboratory results are attached.
5) All other monitoring was performed in accordance with the permit and reported during the year as required and three
(3) copies of certified laboratory results are attached.
6) The facility did not exceed any of the Pollutant Concentration Limits in 15A NCAC 021' .l 105(a) or the Pollutant
Loading Rates in 15A NCAC 02T .l 105(b) (applicable to 40 CFR Part 503 regulated facilities).
7) All general requirements in as specified in the Land Application Permit were complied with (applicable to 40 CFR Part
503 regulated facilities).
8) All monitoring and reporting requirements in 15A NCAC 02T .l 1 I 1 were complied with (applicable to 40 CFR Part
503 regulated facilities).
9) All operations and maintenance requirements in the permit were complied with or, in the case of a deviation, prior
authorization was received from the Division of Water Resources.
10) No contravention of Ground Water Quality Standards occurred at a monitoring well or explanations of violations are
attached to include appropriate actions and remediations.
1 1) Vegetative cover was maintained and proper crop management was performed on each site receing residuals, as
specified in the permit.
12) No runoff of residuals from the application sites onto adjacent property or nearby surface waters has occurred.
13) All buffer requirements as specified on the permit were maintained during each application of residuals.
Part C - Certification-
"] certify, under penalty of law, that the above information is, to the best of my knowledge and belief, true, accurate,
and complete. I am aware that there are significant penalties for submitting false information, including the
possibility of fines and imprisonment for knowing violations."
Laura .. K Ok -T6u-v1 MoA! er
Permittee Name and Ti e (type or print)
4/14;" a - -r� 03 % ! /Z.1
Signature of Preparer* Date
(if different from Permittee)
* Preparer is defined in 40 CFR Part 503.9 (r) and 15A NCAC 02T
3 aaal
Si nature of Permittee I bate
SiZiiure of land Applier
31-;%
Date
`fdifferent from Permittee and Preparer)
1 102 (26) DENR FORM ACF (12/2006)