WQ0000430_Field Transfer Letter_20221221

ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
LARRY WRIGHT — PLANT SUPERVISOR
CITY OF CHERRYVILLE
116 SOUTH MOUNTAIN STREET
CHERRYVILLE, NORTH CAROLINA 28021
Dear Mr. Wright:
NORTH CAROLINA
Environmental Quality
December 21, 2022
Subject: Notice of Field Transfer
Permit No. WQ0000430
City of Cherryville Class B
Residuals Program
Residuals Management System
Gaston County
The Division of Water Resources has received and approved a request to transfer the fields listed
below from the subject permit to Permit No. WQ0016247. Attached are copies of the Land Owner
Agreements authorizing this transfer.
Land Owner
Field / Site
County
Acres
Jason Huitt
NC-LT-107-01
Lincoln
10.7
Jason Huitt
NC-LT-107-02
Lincoln
12
C & J Farms of Vale Inc.
NC-LT-107-03
Lincoln
17
Calvin Wehunt
NC-LT-107-04
Lincoln
10.9
C & J Farms of Vale Inc.
NC-LT-107-05
Lincoln
17.8
C & J Farms of Vale Inc.
NC-LT-107-06
Lincoln
9.5
Daniel Wayne Gilbert
NC-LT-120-02
Lincoln
27.6
Daniel Wayne Gilbert
NC-LT-120-03
Lincoln
11
Please be advised that as of December 20, 2022, the City of Cherryville shall not land apply
residuals to the fields listed above. Doing so shall be a violation of G.S. 143-215.11 and may subject
you to appropriate enforcement actions pursuant to G.S. 143-215.6A., 613., and 6C. Civil penalties of
up to $25,000 per day per violation may be assessed.
Since the subject fields are no longer part of Permit No. WQ0000430, you may submit a permit
modification request to modify the Attachment B, or you may elect to modify the Attachment B during the
permit renewal process.
� North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11617 Mail Service Center I Raleigh, North Carolina 27699-1617
NORTH GAROLINA i
gewaM o� Emlmampndl qual'� /`� 919.707.9000

Page 2 of 2
If you need additional information regarding this notice, please contact
Erick Saunders at [phone] or [e-mail].
Sincerely,
Nathaniel D. Thornburg, Branch Chi
Division of Water Resources
cc: Mooresville Regional Office, Water Quality Regional Operations Section (Electronic Copy)
Laserfiche File (Electronic Copy)

DWR
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Division of Water Resources
LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. [Unless otherwise noted, the Applicant shall submit one original and two copies of the application and
supporting documentation
For more innformalion, visit the Water Quality Permitting Section's Non-Dischurge Perin itling Uni
General -- This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class S residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC U?'l . 1100, Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below,
A. Land Owner Agreement (FORM: LOA 06-16):
[+Submit the completed and appropriately executed Residuals Source Certification (FORM: LASC 06-16) form. Please do not
make any unauthorized content changes to this form, If necessary for clarity or due to space restrictions, attachments to the
application may be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
21"Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
2�A copy of the completed and appropriately executed agreement must be provided to the Iandowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
Tile undersigned landowner or his representative hereby permits:
Applicant's name: Jon CC pP. j'11, ►
hereinafter referred togas the Permittee, to land apply residuals from the following facility(les) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Site/Field 1D
Lease
(yes/no)
Land Use or
Cropping Patterns
intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
1- 10 7` (
�}
The landowner or his representative receives, in consideration, full use of (lie nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
FORM: LOA 06-16 Page 1 of 3

I. STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the sites) specified by this Agreement.
2. Should the landowner or his representative lease or otherwise permit the use of the land application sites) to a third party, the landowner shall
be responsible to ensure that the third party agrees and complies with the terns and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all oFthe site restrictions (under Section II) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1636
Mail Service Center, Raleigh, NC 27699-1636.
S. The Pennittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the
land application site(s).
6. The Penn ittee has provided the landowner or his representative with information and data concerning the residuals land application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of
the equipment used by the Permittee.
7, The Pennittee will provide the landowner or his representative with it copy of the residuals permit prior to commencement of any residuals
land application event and a copy of the results of each soil analysis.
8. if the sail pH of the land application sites) is not maintained at 6,0 or greater, sufficient amounts of Iime shall be applied to achieve a final
soil pH of at least 6.0, unless an agronomist provides information indicating that the pH of the soil, residuals and lime mixture its suitable For
the specified crop,
9, The landowner or his representative and the Penni[tee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Penn ittee with 'information regarding the amount and analysis of other sources of
nutrients (e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
i 1, The landowner or his representative will inform the Perin ittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to each planting season to enable the Permittec to amend this Agreement and schedule residuals land
application events at appropriate periods.
12, Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Pennittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Pennittee, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the terms and conditions of the permit; take necessary leach ate, surface water, groundwater, or soil samples during the
tern of, and 12 months after termination of, this Agreement.
Il. RESTRICTIONS;
1. Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public access to the land
application site(s) during active use and for the 12-month period following a residuals land application event. Such controls may include the
pasting of signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s) for a 30-day period following a residuals land application event. Land application
sites that are to be used for grazing shall have fencing that will be used to prevent access during these periods after such residuals land
application events.
3. Food crops, feed crops, and fiber crops shall not be harvested for a 30-day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are totally above the land surface shall not be harvested for a 14-
month period following a residuals land application event.
5. Food crops with harvested parts below the surface of the land shall not he harvested for a 20-month period fallowing a residuals land
application event when the residuals remain on the land surface for four months or longer prior to incorporation into the sail.
6. Food crops with harvested parts below the surface of the land shall not be harvested for a 38-month period following a residuals land
application event when the residuals remain on the land surface for less than four months prior to incorporation i n I a the sail.
7. Turf grown on land where residuals are applied shall not be harvested for a 12-month period Following a residuals land application event.
I I LALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 02L .0107(d) prohibits water supply wells within the compliance boundary. However, 15A NC'AC 021 .0105t lr l allows the
compliance boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance
boundary provided the groundwater standards can be met at the newly -established compliance boundary, Please mark one of the following;
❑ A re -defined compliance boundary is needed for fields) ID:
(Please include the rationale for the requested re -location of the compliance boundary and attach a trap showing the newly proposed
compliance boundary to the application package)
[+?j A re -defined compliance boundary is not needed for this site.
IV.NOWLEDCEMENT OF FIELD TRANSFER: (if needed)
FT
he land application field}s) ID: _ T 10 '7 ` I , Z _, is currently permitted under another
residuals land application program; Permit Number WQ: D Dad it 37 The land owner hereby acknowledge that by signing this
agreement, he/she is requestin that the field(s) be removgFd from the�Previousl permitte residuals land application program and transferred
into the new program;_ < <., t.1�5irrn rf6"rul m..1 I DO i1� L `7
(Name of the new program)
FORM: LOA 06-16 Page 2 of

Landowner's Certification:
I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to make decisions
regarding the use of the land application site(s) on behalf of other deeded landowners OR that I am otherwise authorized, through
a power of attorney or other legal delegation, to make decisions regarding the use of the land application site(%) on behalf of the
deeded landowners. I certify that the above -referenced land application site(s) are not included in any waste disposal contract or
agreement with another municipality, contractor, or other permitted entity. Furthermore, I certify that I have read this Agreement,
understand the stipulations, restrictions, alternatives for water supply wells inside the compliance boundary, acknowledgement of
field transfer, and do hereby grant permission to the Permittee to land apply residuals to the land application site(s) as specified
herein.
Landowner name:
Address: 2 ]_ W
_51'5 " n riu a T
L,
City: L_,I Cey�L State:
Phone: _70 L4 . S_3 4 - 0f6S1 E-mail address: -�
Signature: ilwr_� &W/- Date:
NORTH CAROLINA, �_ `s.i c ° A
I, the undersigned Notary Public do hereby certify that
Zip
COUNTY
��5�ah tlr 14-
1�­- -ZL
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
fit~
WITNESS my hand and official sea[ this the
day of F� 0uAt'y 20 2. Z
Signature and seal: mix! V. ✓ham
My commission expires: Ly 21��-
Lessee's/Operator's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name:
Address:
City:
Phone:
Signature:
Permittee's Certification:
State:
E-mail address:
Date:
Zip:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name:��r,
Signature: � r Date: —"7 z
FORM. LOA 06-16 Page 3 of 3

I U
State of North Carolina
Departnictit of Environment and Natural Resources
Division of Water Resources
Division of Water Iesources
LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted, the Applicant shall submit one original and two collies of the application and
sungortiva documentation
For more infornialion, visit lire Water Quality Permilling Seclion's Nun-Uischryge PermieliyLg Uny
General —'This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class g residuals (may include water treatment plant or other type residuals) in accordance with l SA NCAC 02 f .i 100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. La d Owner Agreement (FORM: LOA 06-16):
Submit the completed and appropriately executed Residuals Source Certification (FORM: LASC 06-16) form. Please do not
make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to the
application may be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
pplicant.
t� A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
Applicant's name: ;& n &��C rm 5 Lr ,L R c J e2302 l—
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Site/Field ID
Lease
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-tilllover-seed)
pasture)
JJ
Q -7-- 3 �f +P
Ak,
n}
124+✓IM I►7r1,
d
rnew �"�L�
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
FORM: LOA 06-16 Page 1 of 3

1. STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity For the sitc(s) specified by this Agrcement.
2. Should the landowner or his representative lease or otherwise permit the use of the land application site(s) to a third party, the landowner shall
be responsible to ensure that the third party agrees and complics with the terms and conditions of this Agreement.
3. The landowner or Itis representative shall adhere to the provisions of tit is Agrcement until all of the site restrictions (under Sect ian 11) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1636
Mail Service Center, Raleigh, NC 27699-1636.
5. The Pennittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the
land application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a descriptian of
the equipment used by the Permittee.
7. The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals
land application event and a copy of the results of each sail analysis.
8. If the soil pH of the land application sites) is not maintained at 6.0 or greater, sufficient arnounts of lime shall be applied to achieve a final
soil pH of at least 6.0, unless an agronomist provides information indicating that tit pH of the soil, residuals and lime mixture is suitable For
the specified crop.
9. The landowner or his representative and the Penn ittee will agree on residuals application rates and schedules based on crop patterns, results of
soil samples, and the permitted application limits.
10. The landowner or his representative will provide the Permittee with information regarding the amount and analysis of other sources of
nutrients (e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application site(s) prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land
application events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application sitc(s) by the Permittee, the landowner, or
his representative prior- to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittec, local officials, and State officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application site(s) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application sitc(s) as required by the permit; copy any records
that must he kept under the terms and conditions of the permit; take necessary leachatc, surface water, groundwater, or soil samples during the
teen of, and 12 months after termination of, this Agreement.
11, RESTRICTIONS:
1. Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public access to the land
application sitc(s) during active use and for the 12-month period following a residuals land application event. Such controls may include the
posting of signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s) for a 30-day period fallowing a residuals land application event. Land application
sites that are to be used for grazing shall have fencing that will be used to prevent access during these periods after such residuals land
application events.
3. Food crops, feed crops, and fiber crops shall not be harvested for a 30-day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are totally above the land surface shall not be. harvested for a 14-
month period following a residuals land application event.
5. Food crops with harvested parts below the surface of the land shall not be harvested for a 20-month period following a residuals land
application event when the residuals remain on the land surface for four months or longer prior to incorporation into the soil.
6. Food crops with harvested parts below the surface of the land shall not be harvested for a 38-month period following a residuals land
application event when the residuals remain on the land surface for less than four months prior to incorporation into the soil.
7. TurFgrown on land where residuals are applied shall not be harvested for a 12-month period following a residuals land application event.
111.ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 02L .4107(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC 02T .0105Ih1 allows the
compliance boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance
boundary provided the groundwater standards can be met at the newly -established compliance boundary. Please mark one of the following;
❑ A re -defined compliance boundary is needed for fields) ID:
(Please include the rationale For the requested re -location of the compliance boundary and attach a map showing the newly proposed
eprnpIIance boundary to the application package)
LB A re -defined compliance boundary is not needed for this site,
IV.ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed
t
The land application fields) ID; - j�� ,fit . �, a� 6 is currently permitted under another
residuals land application program; Permit Number WQ Q o0 0 4{ 3 y The land owner hereby acknowledge that by signing this
agreement, he/she is requesting that the freld(s be removed from the previously permitted residuals land application program and transferred
into the new program; W Q D G t �Q`l_
(Name of the new program)
FORM: LOA 06-16
Page 2 of 3

Lando►vner's Certification:
I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to make decisions
regarding the use of the land application site(s) on behalf of other deeded landowners OR that I am otherwise authorized, through
a power of attorney or other legal delegation, to make decisions regarding the use of the land application site(s) on behalf of the
deeded landowners. I certify that the above -referenced land application site(s) are not included in any waste disposal contract or
agreement with another municipality, contractor, or other permitted entity. Furthermore, I certify that I have read this Agreement,
understand the stipulations, restrictions, alternatives for water supply wells inside the compliance boundary, acknowledgement of
field transfer, and do hereby grant permission to the Permittee to land apply residuals to the land application site(s) as specified
herein.
Landowner name: L rn l V<<n WY, Lo +'
Address: e � lVrJrogAn ?arlfY"_ f2G
City: 1-1ir1 CN
S tate: .I✓ C-
Phone: ! c7 - �'[ °t �D E-mail address:
5ignatur , Date:
Zip:
NORTH CAROLINA, �- -LA Cs 1r COUNTY 11 �I I, the undersigned Notary Public do hereby certify that Lyt WL IUA
a-'Saq &
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.�o111111jr1o`
WITNESS my hand and official seal this the}� ;��,�pV�_..!�O
day of
Signature and seal: W(►�
My commission expires:
Lessee'slaperatnr's Certification:
20 7 Z
i±
yco\36 . -'�
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name:
Address:
City:
Phone:
Signature:
Permittee's Certification:
State:
E-mail address:
Date:
Zip:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name:
jcotn
Signature: wj��_Date
FORM: LOA 06-16 Page 3 of 3

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Dlvlsion of Water Resources
LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted, the Applicant shall submit one original and two conies of the application and
supporting documentation
For more information, visil the Water Quality Permitling Sections Non -Discharge Permitting Chit
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class B residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 06-16):
Submit the completed and appropriately executed Residuals Source Certification (FORM' LASC 06-16) form. Please do not
make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to the
application may be made, as long as the attachments are munbered to correspond to the section and item to which they refer.
[Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
Ee'A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereb permits:
M r
Applicant's name:/I [ ��� 5�r rn i'e r+•r~ t—
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Site/FieId ID
Lease
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-tililover-seed/
pasture)
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
FORM: LOA 06-16 Pagel of 3

I. STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the sites) specified by this Agreement.
2. Should the landowner or his representative lease or otherwise permit the use of the land application sites) to a third party, the landowner shall
be responsible to ensure that the third party agrees and complies with the terms and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions (under Section 11) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCFDENR-DWR, Non -Discharge Permitting Unit, 1636
Mail Service Center, Raleigh, NC 27699-1636.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the land application site(s) to a new
landowner, In addition, the current landowner shall give a notice to the new landowner that gives Tull details of the residuals applied at the
land application site(s).
6. The Permittee has provided the landowner or his representative with information and data concerning the residuals land application program,
including an analysis of constituents of the residuals, residuals application methods, schedules for typical cropping patterns, a description of
the equipment used by the Permittee,
7, The Permittee will provide the landowner or his representative with a copy of the residuals permit prior to commencement of any residuals
land application event and a copy of the results of each soil analysis.
8. If the soil pH of the land application site(s) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a final
soil pH of at least 6.0, unless an agronomist provides information indicating that the pl-I of the soil, residuals and lime mixture is suitable for
the specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns, results of
sail samples, and the permitted application limits.
10. The landowner or liis representative will provide the Permittee with information regarding the amount and analysis of other sources of
nutrients (e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Permittee of any revisions or modifications to the intended use and cropping patterns for
the land application sites) prior to each planting season to enable the Permittee to amend this Agreement and schedule residuals land
application events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Permittee, local officials, and Stale officials or their representatives to; enter and
inspect any property, premises, or place on or related to the land application sites) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the terns and conditions of the permit; take necessary toachate, surface water, groundwater, or so it samples during the
term of, and 12 months after termination of, this Agreement.
II. RESTRICTIONS:
1. Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public access to the land
application site(s) during active use and for the 12-month period following a residuals land application event. Such controls may include the
posting of signs that indicate the activities being conducted at the land application site(s).
2. Animals shall not be grazed on the land application site(s) for a 30-day period following a residuals land application event. Land application
sites that are to be used for grazing shall have fencing that will be used to prevent access during these periods after such residuals land
application events.
3. Food crops, feed crops, and fiber crops shall not be harvested for a 30-day period following a residuals land application event.
4. Food crops with harvested parts that touch the residuals/soil mixture and are totally above the land surface shall not be harvested for a 14-
month period foIlowiing a residuals land application event.
S. food crops with harvested parts below the surface of the land shall not be harvested for a 20-month period following a residuals land
application event when the residuals remain on the land surface for four months or longer prior to incorporation into the soil.
6. Food crops with harvested parts below the surface of the land shall not be harvested for a 38-month period following a residuals land
application event when the residuals remain on the land surface for less than four months prior to incorporation into the soil.
7. Turf grown on land where residuals are applied shall not be harvested for a 12-month period following a residuals land application event,
III.ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 02L .0107(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC 02T .0 i 05f h] allows the
compliance boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance
boundary provided the groundwater standards can be met at the newly -established compliance boundary. Please marls one of the following;
❑ A re -defined compliance boundary is needed for fields) ID:
(Please include the rationale for the requested re -location
compliance boundary to the application package)
V(A re -defined compliance boundary is not needed for this site.
of the compliance boundary and attach a map showing the newly proposed
IV. AC IOWLEDGEMENT OF FIELD TRANSFER: of needed
The land application field(s) ID: L a, 3 is currently permitted under another
residuals land application program; Permit Number WQ:_ 00. C) The land owner hereby acknowledge that by signing this
agreement, he/she is requesting t t the field(s) be removed from thp previously permitted residuals land application program and transferred
into the new program; W&ri r• cl
(Name of the new program)
FORM: LOA 46-16
Page 2 ❑f 3

Landowner's Certification:
I certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to make decisions
regarding the use of the land application site(s) on behalf of other deeded landowners OR that I am otherwise authorized, through
a power of attorney or other legal delegation, to make decisions regarding the use of the land application site(s) on behalf of the
deeded landowners. I certify that the above -referenced land application site(s) are not included in any waste disposal contract or
agreement with another municipality, contractor, or other permitted entity. Furthermore, I certify that I have read this Agreement,
understand the stipulations, restrictions, alternatives for water supply wells inside the compliance boundary, acknowledgement of
field transfer, and do hereby grant permission to the Permittee to land apply residuals to the land application site(s) as specified
herein.
Landowner name: G
(�� L 6
okAddress: D�F` Cl .5611
City: V 1 f �_ State: AIV
Phone: _j0 _ 11 -7 E-mail address:
Signature: Date:
NORTH CAROLINA, _ 1—"A(., L r1 _ COUNTY
I, the undersigned Notary Public do hereby certify that "G"' n * - lSv�itd
Zip:
1,�_ -J_16- 2 (
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WIT><TESS h nd and off-icial seal this the
2,y
Lily a
day of ► z 0 k rT
Signature and seal:
My commission expires: �_ 2 �
Lessee's/Operator's Certification:
, 20..
91l
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name:
Address:
City:
Phone:
Signature:
Permittee's Certification.
State:
E-mail address:
Date:
Zip:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name: ho ,o rl - a,
Signature:
Date: c
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