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HomeMy WebLinkAboutWQ0002834_2022 Residual Annual Report_20230301 (2)Initial Review Reviewer Nathaniel.Thornburg Is this submittal an application? (Excluding additional information.) * Yes No If not an application what is the submittal type?* Annual Report Residual Annual Report Additional Information Other Annual Report Year* 2022 Permit Number (IR) * WQ0002834 Applicant/Permittee Town of Burnsville Email Notifications Does this need review by the hydrogeologist? * Yes No Regional Office Asheville CO Reviewer Admin Reviewer Submittal Form Project Contact Information Please provide information on the person to be contacted by NDB Staff regarding electronic submittal, confirmation of receipt, and other correspondence. Name* Paul Isenhour Email Address* waterqualitylabs@yahoo.com Project Information ......................... Application/Document Type* New (Fee Required) Modification - Major (Fee Required) Renewal with Major Modification (Fee Required) Annual Report Additional Information Other Phone Number* 8288986277 Modification - Minor Renewal GW-59, NDMR, NDMLR, NDAR-1, N DAR-2 Residual Annual Report 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://edoes.deq.nc.gov/Forms/NonDischarge_Monitoring_Report Permit Type:* Wastewater Irrigation High -Rate Infiltration Other Wastewater Reclaimed Water Closed -Loop Recycle Residuals Single -Family Residence Wastewater Other Irrigation Permit Number:* WQ0002834 Has Current Existing permit number Applicant/Permittee Address* 843 Pine Swamp RD Facility Name* Town of Burnsville Class A Residuals Program Please provide comments/notes on your current submittal below. Annual residuals report for Burnsville At this time, paper copies are no longer required. If you have any questions about what is required, please contact Nathaniel Thornburg at nathaniel.thornburg@ncdenr.gov. Please attach all information required or requested for this submittal to be reviewed here. (Application Form, Engineering Plans, Specifications, Calculations, Etc.) Water Quality Labs_20230301_142933.pdf 3.42MB Upload only 1 PDF document (less than 250 MB). Multiple documents must be combined into one PDF file unless file is larger than upload limit. * 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 Peal 13190hoay' Submission Date 3/1/2023 RESIDUALS ANNUAL REPORT COVER LETTER TOWN OF BURNSVILLE ITEMS INCLUDED: Cover Letter FORM DMSDF FORM DMSDF (supp) FORM RSSF FORM RSSF — B LAB SHEETS FORM PVRF 2T One pile of compost was made for the 2022 year. It was completed at the end of April. Compost was tested and distributed there after. If you have any questions, feel free to contact Paul Isenhour by email at waterqualitylabs@yahoo.com or by phone at 828-898-6277. v is i Or U 0 U m co w 0 W O i z O U ❑off .a 4J �-1 O eta a tn C� t-- A A W O q 0 z Q3 U U I^ COD 0 0 b 0 cq � a� ro O o A Qn � W rn A a z r�A N U V W od C a� .0 y o m v 6. od yy W y a O • a U GO L � � 10 � Ca x c U x 41 etl LU `� O O cc 0 d Z is A v � 0 R � o � o w o Z 1 ❑x❑ v tN U �i�i w �o a o .c 40. a � b o 4. 01 '4- boCd a G , cC O W O � � 0 �j o c. sue. ^G O u po fn r..�a It m n5 ai +; al � +-� O •� CJ �' bA Qr O � •O �.+ m •}� O A O 4. S bqqA'Z .0 PC o' o >40. a �, �cz In t } 0 cz Aq o u i Q) � V � 71 O O O O O ul N 00 o N cn 0 CZ N cd 0 cz [� Cd U � � O � a 0 a o �5 W v� Q� b A � a z; � � d u i O C/] d O un o~ Gz, Q Q O w a rA ro G 4� s m a CC U cl LLq O Q aU+ O O � U 0 CIO N � l V) N V m 00 'n N 00 O v M ,—, N N b b U�z��z��r-���zzzz O U Go C/] � 0 N sU. C . td cad as o as U v� ti e�e3 a iU ILI O d z a w O N Cd U M U U a US ro ai N O o U o 0 z 0 H H I I z II I�INIII aceAnalXical www.pacLiabs.com Pace Analytical Services, LLC 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 ANALYTICAL RESULTS Project: Burnsville Sludge 5/3122 Pace Project No.: 92603547 Sample: Burnsville Sludge Lab lE): 92603547001 Collected: 05/03/22 08:00 Received: 05/06/22 13:50 Matrix: Solid Results reported on a "dry weight" basis and are adjusted for percent moisture, sample size and any dilutions. Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual 8081 TCLP Pesticides RVE Analytical Method: EPA 8081B Preparation Method: EPA 3514C Leachate Method/Date: EPA 1311; 05/12/22 15:04 Initial pH: 6.31; Final pH: 5 Pace Analytical Services - Charlotte gamma-BHC (Lindane) Nb ug/L 0.50 1 05/16/22 13:14 05/17/22 13:50 58-89-9 Chlordane (Technical) ND ug1L 3.0 1 05/16/22 13:14 05/17/22 13:50 57-74-9 Endrin ND ug/L 0.50 1 05/16/22 13:14 05/1712213:50 72-20-8 Heptachlor ND ug/L 0.50 1 05/16/22 13:14 0511712213:50 76-44-8 Heptachlor epoxide ND ug/L 0.50 1 05/1612213:14 05/1712213:50 1024-57-3 Methoxychlor ND ug/L 1000 1 0511612213:14 05/17/2213:50 72-43-5 Toxaphene ND ug/L 3.0 1 05116/2213:14 05117/221150 8001-35-2 Surrogates Decachlorobiphenyl (S) 69 % 10-200 1 05/16/22 13:14 05/17/22 13:50 2051-24-3 Tetrachloro-m-xylene (S) 59 % 10-182 1 05/16/22 13:14 05/17/22 13:50 877-09-8 6010 MET IC Analytical Method: EPA 6010D Preparation Method: EPA 3050E Pace Analytical Services - Asheville Arsenic ND mglkg 9.4 1 05/11/22 08:55 05/1612212:12 7440-38-2 Cadmium 1.6 mg/kg 0.38 1 05/11/22 08:55 05/16/22 12:12 7440-43-9 Calcium 17400 mglkg 94.1 1 05/11/22 08:55 05/16/22 12:12 7440-70-2 Chromium 58.5 mg/kg 1.9 1 05/11/22 08:55 05/16/22 12:12 7440-47-3 Copper 356 mg/kg 18.8 1 05/11/22 08:55 05/16/22 12:12 7440-50-8 Lead 25.7 mglkg 3.8 1 05/11/22 08:55 05/16/22 12A2 7439-92-1 Magnesium 5300 mglkg 37.6 1 05111/2208:55 0511612212:12 7439-95-4 Molybdenum ND mglkg 18.8 1 05/11/22 08:55 05/1612212:12 7439-98-7 Nickel 36.3 mglkg 1.9 1 05/11/22 08:55 05/16/22 12:12 7440-02-0 Potassium 6580 mglkg 1880 1 05/11/22 08:55 05/16/22 12:12 7440-09-7 Selenium 7.2 mglkg 3.8 1 05/11/22 08:55 05/16/22 12:12 7782-49-2 Sodium ND mglkg 1880 1 05/11/22 08:55 05/16/22 12:12 7440-23-5 Zinc 1020 mglkg 3.8 1 05/11/22 08:55 05/16/22 12:12 7440-66-6 6010 MET ICP, TCLP Analytical Method: EPA 6010D Preparation Method: EPA 3010A Leachate MethodlDate: EPA 1311; 05/12/22 15:04 Initial pH: 6.31; Final pH: 2 Pace Analytical Services -Asheville Arsenic ND mg1L 0.050 1 05/14/22 00:14 05/26/22 17:02 7440-38-2 Barium 0.25 mg/L 0.25 1 05/14/22 00:14 05/26/22 17:02 7440-39-3 Cadmium ND mg/L 0.0050 1 05/14/22 00:14 05126/22 17:02 7440-43-9 Chromium ND mg/L 0,050 1 05/14/22 00:14 05/26/22 17:02 7440-47-3 Lead ND mg/L 0.025 1 05/14/22 00:14 05/26/22 17:02 7439-92-1 Selenium ND mg/L 0.10 1 05/14/22 00:14 05/26/22 17:02 7782-49-2 Silver ND mg1L 0.025 1 05/14/22 00:14 05/26/22 17:02 7440-22-4 Sodium Adsorption Ratio, SAR Analytical Method: EPA 6010D Pace Analytical Services -Asheville Sodium Adsorption Ratio 0.0 meglL 1 05/30/22 08:06 REPORT OF LABORATORY ANALYSIS N2 This report shall not be reproduced, except in full, Date: 06/07/2022 11:55 AM without the written consent of Pace analytical Services, LLC. Page 4 of 45 aceAnalytical www.pacelabssom Pace Analytical Services, LLC 9800 Kincey Ave. Suite 100 Huntersville, NC 26078 (704)875-9092 ANALYTICAL RESULTS Project: Burnsville Sludge 513122 Pace Project No.: 92603547 Sample: Burnsville Sludge Lab ID: 92603547001 Collected: 05/03/22 08:00 Received: 05/06/22 13:50 Matrix: Solid Results reported on a "dry weight" basis and are adjusted for percent moisture, sample size and any dilutions. Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual 7470 Mercury, TCLP Analytical Method: EPA 7470A Preparation Method: EPA 7470A Leachate Method/Date: EPA 1311; 05/12/22 15:04 Initial pH: 6.31; Final pH: 2 Pace Analytical Services -Asheville Mercury ND mg1L 0.00020 1 05/14/2217:22 05/17/2214:13 7439-97-6 7471 Mercury Analytical Method: EPA 7471 B Preparation Method: EPA 7471 B Pace Analytical Services - Asheviile Mercury 0.85 mg/kg 0.046 2 05/11/22 11:52 05/17/22 08:50 7439-97-6 CO 8270E TCLP RVE Analytical Method: EPA 8270E Preparation Method: EPA 3510C Leachate Method/Date: EPA 1311; 05/12/22 15:04 Initial pH: 6.31; Final pH: 5 Pace Analytical Services - Charlotte 1,4-Dichlorobenzene ND uglL 50.0 1 05116/2211:09 05117/2214:16 106-46-7 2,4-Dinitrotoluene ND uglL 50.0 1 05116/2211:09 0511712214:16 121-14-2 Hexachioro-1,3-butadiene ND ug/L 50.0 1 05/16/2211:09 05/1712214:16 87-68-3 Hexachlorobenzene ND ug1L 50.0 1 05/16/2211:09 05117/2214:16 118-74-1 Hexachloroethane ND ug1L 50.0 1 05116/2211:09 05/17/2214:16 67-72-1 2-Methylphenol(o-Cresol) ND ug1L 50.0 1 05/16/2211:09 0511712214:16 95-48-7 3&4-Methylphenol(m&p Cresol) ND ug/L 50.0 1 05/16/22 11:09 05/17/22 14:16 15831-10-4 Nitrobenzene ND ug/L 50.0 1 0511612211:09 05117/2214:16 98-95-3 Pentachlorophenol ND uglL 100 1 05/16/2211:09 05/17/2214:16 87-86-5 Pyridine ND uglL 50.0 1 0511612211:09 05/1712214:16 110-86-1 v1 2,4,5-Trichlorophenol ND uglL 50.0 1 05116/2211:09 0511712214:16 95-95-4 2,4,6-Trichlorophenol ND uglL 50.0 1 05/16/2211:09 05/1712214:16 88-06-2 Surrogates Nitrobenzene-d5 (S) 40 % 10-144 1 05/16/22 11:09 05/17/22 14:16 4165-60-0 2-Fluorobiphenyl (S) 34 % 10-130 1 05/16/22 11:09 05/17122 14:16 321-60-8 Terphenyl-d14 (S) 46 % 34-163 1 05/16/22 11:09 06/17/22 14;16 1718-51-0 Phenol-d6 (S) 19 % 10-130 1 05/16/22 11:09 05/17/22 14:16 13127-88-3 2-Fluorophenol (S) 29 % 10-130 1 05/16/22 11:09 05/17/22 14:16 367-12-4 2,4,6-Tribromophenol (S) 45 % 10-144 1 05/16122 11:09 05/17/22 14:16 118-79-6 8260D MSV TCLP Analytical Method: EPA 8260D Leachate Method/Date: EPA 1311; 05/12/22 13:10 Pace Analytical Services - Charlotte Benzene ND uglL 100 20 05/14/22 06:21 71-43-2 2-13utanone (MEK) ND uglL 200 20 05/14/22 06:21 78-93-3 Carbon tetrachloride N❑ uglL 100 20 05/14/22 06:21 56-23-5 Chlorobenzene ND uglL 100 20 05/14/22 06:21 108-90-7 Chloroform ND uglL 100 20 05/14/22 06:21 67-66-3 1,4-Dichlorobenzene N❑ uglL 100 20 05/14/22 06:21 106-46-7 1,2-Dichloroethane ND uglL 100 20 05/14/22 06:21 107-06-2 1,1-Dichloroethene ND uglL 100 20 05114/2206:21 75-35-4 Tetrachloroethene ND uglL 100 20 05/14/22 06:21 127-18-4 Trichloroethene ND uglL 100 20 05114122 06:21 79-01-6 Vinyl chloride ND uglL 100 20 05/14/22 06:21 75-01-4 REPORT OE LABORATORY ANALYSIS This report shall not be reproduced, except in full, Date: 06/07/2022 11:55 AM without the written consent of Pace Analytical Services, LLC. Page 5 of 45 Qo aceAnalyfical www.pacelabs.com Pace Analytical Services, LLC 9800 Kincey Ave. Suite 100 Huntersville, NC 28078 (704)875-9092 ANALYTICAL RESULTS Project: Burnsville Sludge 513122 Pace Project No.: 92603547 Sample: Burnsville Sludge Lab ID: 92603547001 Collected: 05/03/22 08:00 Received: 05/06/22 13:50 Matrix: Solid Results reported on a "dry weight' basis and are adjusted for percent moisture, sample size and any dilutions. Parameters Results Units Report Limit DF Prepared Analyzed CAS No. Qual 8260D MSV TCLP Analytical Method: EPA8260D Leachate Method/Date: EPA 1311; 05/12/22 13:10 Pace Analytical Services - Charlotte Surrogates 1,2-Dichloroethane-d4 (S) 97 % 70-130 20 05/14/22 06:21 17060-07-0 Toluene-0 (S) 105 % 67-135 20 05/14/22 06:21 2037-26-5 4-Bromofluorobenzene (S) 99 % 70-130 20 05/14/22 06:21 460-00-4 254OG Total Percent Solids Analytical Method: SM 2540G-2011 Pace Analytical Services - Charlotte Total Solids 25.1 % 0.10 1 05/11/22 17:55 H1 Percent Moisture Analytical Method: SW-846 Pace Analytical Services -Charlotte Percent Moisture 74.9 % 0.10 1 05/11/22 17:44 N2 9045 pH Soil Analytical Method: FPA 9045D Pace Analytical Services -Asheville pH at 25 Degrees C 8.2 Std. Units 0.10 1 05/13/22 10:06 H3 9095 Paint Filter Liquid Test Analytical Method: EPA 9095B Pace Analytical Services -Asheville Free Liquids PASS 1.0 1 05/16/22 12:14 Plant Available Nitrogen Analytical Method: None Pace Analytical Services -Asheville Plant Available Nitrogen 9310 mglkg 1 05/31/22 14:13 N2 350.1 Ammonia Analytical Method: EPA 350.1 Rev 2.0 1993 Mod. Preparation Method: EPA 350.1 Rev 2.0 1993 Mod, Pace Analytical Services -Asheville Nitrogen, Ammonia 2920 mglkg 84.3 3 05/12/22 12:57 05/13122 10:44 7664-41-7 351.2 Total Kjeldahl Nitrogen Analytical Method: EPA 351.2 Rev 2.0 1993 Preparation Method: EPA 351.2 Rev 2.0 1993 Pace Analytical Services -Asheville Nitrogen, Kjeldahl, Total 29000 mg/kg 1730 10 05/25/22 19:50 05/27/22 06:32 7727-37-9 353.2 Nitrogen, N021NO3 Analytical Method: EPA 353.2 Rev 2.0 1993 Preparation Method: EPA 353.2 Rev 2.0 1993 Pace Analytical Services -Asheville Nitrogen, NO2 plus NO3 21.6 mg/kg 15.7 1 05/11/22 00:56 05/11/22 02:38 H3 Nitrogen, Nitrate 21.6 mglkg 15.7 1 05/11/22 00:56 05/11/22 02:38 14797-55-8 Nitrogen, Nitrite ND mg/kg 15.7 1 05/11/22 00:56 05111122 02;38 14797-65-0 H3 365.1 Phosphorus, Total Analytical Method: EPA 365.1 Rev 2.0 1993 Preparation Method: EPA 365.1 Rev 2.0 1993 Pace Analytical Services -Asheville Phosphorus 16700 mglkg 192 50 05/11/2217:26 05/11/2219:47 7723-14-0 Date: 06/07/2022 11:55 AM REPORT OF LABORATORY ANALYSIS This report shall not be reproduced, except in full, without the written consent of Pace Analytical Services, LLC, Page 6 of 45 WATER QUALITY LAB & OPERATIONS, INC. P.O. BOX 1167 BANNER ELK, NC 28604 (828) 898-6277 CLIENT: TOWN OF BURNSVILLE LOGIN TIME: ADDRESS: SAMPLER: CITY: RECEIVED DATE: STATE: NC REPORTED DATE: ID#: NCO020290 REX WOODY 3-May-22 4-May-22 ANALYSIS LSID # ANALYSIS MQL's UNITS METHOD SAMPLE ANALYSIS INT RESULTS LOCATION DATE TOTAL SOLIDS 38.3 % BURN. SLUDGE FECAL 1 258.0 1.00 MPN/G SM9221 E2 #2 3-May-22 PIIWPS TOTAL SOLIDS 37.1 % BURN. SLUDGE FECAL 2 444.0 1.00 MPNIG SM9221 E2 #2 3-May-22 PIIWPS TOTAL SOLIDS 37.3 % BURN. SLUDGE FECAL 3 123.0 1.00 MPNIG SM9221 E2 #2 3-May-22 PIIWPS TOTAL SOLIDS 36.9 % BURN. SLUDGE FECAL 4 383.0 1.00 MPNIG SM9221 E2 #2 3-May-22 PIIWPS TOTAL SOLIDS 37.7 % BURN. SLUDGE FECAL 5 453.0 1.00 MPNIG SM9221 E2 #2 3-May-22 PIIWPS TOTAL SOLIDS 36.6 % BURN. SLUDGE FECAL 6 333.0 1.00 MPNIG SM9221E2 #2 3-May-22 PIIWPS TOTAL SOLIDS 38.1 % BURN. SLUDGE FECAL 7 288.0 1.00 MPNIG I SM9221 E2 #2 rMay-22 PIIWPS REPORTED BY: NC CERTIFIED LAB # 544 PAUL ISENHOUR, SUPERVISOR gz� ( Q II- �, ---, P"') -6�cJ�_ Pile Number zt)z TOWN OF BU RNSVI LLE Date Initials Tempt Temp 2 Temp 3 Temp 4 Temp 5 Temp 6 Temp 7 Temp 8 j 7 �- '� ? F L r F F �" F F F F F L C, F �� F F "� F F F F C-f ,: -7 �F i_ F F [ F '' F F F F Z7 CL -' F L C F F F F F F F 1, F F F. F F F F F F F F ice{ F F F _ 2 L-0 7L• F I_56, F F �2f .y,_ F �---F• jam, F F F F j ti S7 F F -9 F O F F F F 'j F S F 1 �[ F (` F C% F F F F F F I U F. 6 F t 1, O F F: F F F F F F F F'". F F l { I F F I )- 3 F f: — F u F F F F F F F �'' F i- F F F F F _5S�F ' _F F F F F F P-t FF F J '-- F F F F - F 6 F F F`. �- F F F F L- I _ 1( r 17 � F 3 F< F ' F( H Lj F F F F Lf 1.- c- v,9 72 F{' F L F ILIL-F F F F F j F .� F lF �`�� F F F F -7J F F F S' F F F F F '- ( 1 7- F.1 F Ste F F f F F F F F S F ;. 5 F 1 L,C) F q+( F F F F F S$ F 5 F [ F f{LfE F F F i3: 2 F 157 F t F . C)F � F F F F F F S F 1—F F F F j) F{ F u� F I 7 F �" 2-- F F F F ) F L-[Z.F F F: F F F F F( L j. F F F �F `j' T-c'f +� zu F ��� F .f 1 F j F� F F F �.I. F, F F '' F ',� F F F _- .: F - r-f F ` F J F fJ F F F F 7 r F F i�` F F F F F F F F F Q F F F F _ F F 47 F F F��� F F F "� F F F F F F F F F F1 F1 F I F F Sampling Date Number of Samples Taken ° Sampling Depth Page of ANN UAL FAI'HUU EN AND VL;C; I OR Al I RAU 11U1N REDUCTION Y()KM (U2T Mules) Facility Name: Town of Burnsville WWTP Name: Town of Burnsville WQ Permit Number: WQ0002834 NPDES Number: NCO020290 Monitoring Period: From l/l/2022 To 12/31/2022 Pathogen Reduction (15A NCAC 02T .1106) - Please indicate level achieved and alternative nerfnrmerl- Class A: Alt. A (time/temp) ❑x Alt B (Alk Treatment)❑ Alt. C (Prior Testing)❑ A1t.D (No Prior Test) IProcess to Further Reduce Pathogens ❑ f applica le to a ernative pefform.W (Class I L only) indi to "Proc s to Furt ier Reduc Pathogens": 0111post ❑x Heat Drying ❑ Heat Treatment ❑ Thermo hilic ❑ Beta Ray ❑ Gamma Ray ❑ Pasteurization ❑ Class B: JAlt. (1) Fecal Density ❑ I Alt. (2) Process to Significantly Reduce Pathogens ❑ f applicable to alternative performed (Class B only) indicate "Process to Significantly Reduce Pathogens": Lime Stabilization ❑ Air Drying ❑ Composting ❑ JAerobic Digestion ❑ Anaerobic Digestion ❑ f applicable to alternative performed (Class A or Class B) complete the following monitoring data: Parameter Allowable Level in Sludge g Pathogen Density Number of Excee- dences Frequency of Analysis y Sample Type Analytical Tech-ni u q Minimum Geo. Mean aximu Units Fecal Colifonn 2 x 10 to the 6th power per gram of total solids MpN 123 303 453 MPN/G 0 annual G SM9221 E2 CFU 1000 mpn per gram of total solid (dry weight) Salmonella bacteria (in lieu of fecal coliform) 3 MPN per 4 grams total solid (dry weight) Vector Attraction Reduction (15A NCAC 02T 11071- Please indicate alternative performed: lt.1 (VS reduction) ❑ Alt. 2 (40-day bench) ❑ Alt. 3 (30-day bench) ❑ IAlt. 4 (Spec. O, uptake) ❑ t. 5 (14-Day Aerobic) ❑x Alt. 6 (Alk. Stabilization ❑ Alt 7 (Drying - Stable) ❑ JAIt. 8 (Drying - Unstable) ❑ t. 9 (Injection) ❑ Alt. 10 (Incorporation) LL No vector attraction reduction alternatives were performed ❑ CERTIFICATION STATEMENT (please check the appropriate statement) l] "I certify, under penalty of law, that the pathogen requirements in 15A NCAC 02T .1106 and the vector attraction reduction requirement in 15A NCAC 02T .1107 have been met." "I certify, under penalty of law, that the pathogen requirements in 15A NCAC 02T .1106 and the vector attraction reduction requirement in 15A NCAC 02T .1107 have not been met." (Please note if you check this statement attach an explanation why you have not met one or both of the requirements.) "This determination has been made under my direction and supervision in accordance with the system designed to ensure that qualified personnel properly gather and evaluate the information used to determine that the pathogen and vector attraction reduction requirements have been met. I am aware that there are significant penalties for false certification including fine and imprisonment." Paul Isenhour, ORC Preparer Name and Title (type or print) gnature of Preparers Land Applier Name and Title (if applicable)(type or print) 2-ZS-a3 Date Signature of Land Applier (if applicable) Date *Preparer is defined in 40 CFR Part 503.9(r) and 15A NCAC 2T .1102 (26)