WQ0031672_Residual Annual Report 2019_20200407

ANNUAL LAND APPLICATION CERTIFICATION FORM
WQ Permit#: ftp ;3 j (fil a County:
Facility Name (as shown on permit):
Land Application Operator: U-Q
Year: c �i
Phone:
Land apphcat' n of residuals as allowed by the permit occurred during tho past calendar year?
El Yes 7No - 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 Summa
Total number of application fields in thepermit:
Total number of fields utilized for land application during the year:
Total amount of dry tons applied during 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 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. J?
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 achieA Ro(J �jf (�t least 6.0 or
the limit specified in the permit.
3) Annual soils analysis were performed on each site receiving residuals during the p�t81tIthree (3) copies
of laboratory results are attached. wr
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 02T .1105(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. I I l 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.
11) 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:
"I 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."
Permittee Name and Ti le (t pe or print) nature of Permittee Date
G
Signature of Preparer*
Date Signature of Land Applier
Date
(if different from Permittee) (if different from Permittee and Preparer)
* Preparer is defined in 40 CFR Part 503.9 (r) and 15A NCAC 02T .1102 (26) DENR FORM ACF (12/2006)

CLASS A ANNUAL DISTRIBUTION AND
WQ PERMIT #: w can();3 I J0 Z FACILITY NA11
PHONE:3'3663s5190 COUNTY:
FACILITY TYPE (please check one):
ACE DISPOSAL CERTIFICATION AND SUMMARY FORM
OPERATOR: _^ E N410 at yo
urfac isposal complete Part A (Source(s) and "Residual In" Volume only) and Part C)
Distribution andyarketing (complete Parts A, B, and C)
Was the facility in operation during the past calendar year? Yes No ❑ — * If No slip parts A, B, C and certify form below
Part A*:
Part B*:
Month
Sources(s) (include NPDES # if
applicable)
Volume (dry tons)
Recipient Information
Amendment/
Bulking Agent
Residual In
Product Out
Name(s)
Volume (dry tons)
Intended use(s)
January
February
March
April
May
June
July
August
September
October
November
December
Total from FORM DMSDF (sup)
Totals:
Annual (dry tons):
Amendment(s) used: Bulking Agent(s) used:
* If more space is required, attach additional information sheets (FORM DMSDF (supp)): Total Number of Form DMSDF (Supp)�
Part C:
Facility was compliant during the past calendar year with all conditions of the land application permit (Yes
(including but not limited to items 1-3 below) issued by the Division of Water Resources: ❑ No > If No, Explain in Narritive
1. All monitoring was done in accordance with the permit and reported for the year as required and three (3) copies of certified laboratory results are attached.
2. All operation and maintenance requirements were compiled with or, in the case of a deviation, prior authorization was received from the Division of Water Resources.
3. No contravention of Ground Water Quality Standards occurred at a monitoring well.
"I 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."
4y�1)
t ature of Permittee Date
**Preparer is defined in 40 CFR Part 503.9(r) and 15A NCAC 2T .l 102 (26)
Signature of Preparer**
(if different from Permittee)
Date
DENR FORM DMSDF (12/2006)