WQ0016247_Modification_20200416

Initial Review
INITIAL REVIEW
Reviewer
Thornburg, Nathaniel
Is this submittal an application?
(Excluding additional information.)*
r Yes r No
Is this a complete
application?*
Complete App Date
r Yes r No
04/17/2020
Project Number*
WQ0016247
Applicant/Permittee
Synagro Central, LLC
Applicant/Permittee
284 Boger Rd Mocksville, NC 27028
Address
Is the owner in BIMS?
r Yes r No
Owner Type
Facility Name
County
Fee Category
Major
Signature Authority
Organization
Synagro Western Piedmont RLAP
Alexander
Signature Authority Title
Signature Authority Email
Document Type (if
non -application)
Email Notifications
Does this need review by the hydrogeologist?*
r Yes r No
Regional Office Mooresville
CO Reviewer Ranveer Katyal: eads\rkatyal
Is the facility in BIMS?
r Yes r No
Fee Amount
395

Admin Reviewer
Below list any additional email address that need notification about a new project.
Email Address
Comments to be added to email notification
Comments for Kendall
Comments for RO
Comments for Reviewer
Comments for Applicant

Submitted Form
Project Contact Information
Rease provide information on the person to be contacted by MB Staff regarding electronic subnittal, confirmation of receipt, and other issues.
........................................................................................................................................................................................................................................................................................................................................................................
Name * Alex Fox
Email Address*
[e-mail]
Project Information
Submittal Type* r New Permit Application
r Renewal
r Annual Report
r Other
Permit Type * r Wastewater Irrigation
r Other Wastewater
r Closed -Loop Recycle
r Single -Family Residence
Wastewater Irrigation
Is a paper copy of the application being submitted?
r Yes r Nor N/A
Permit Number WQ0016247
currently has project
ApplicantTermittee * Synagro Central, LLC
Applicant/Permittee 284 Boger Rd Mocksville, NC 27028
Address*
Facility Name * Synagro Western Piedmont RLAP
Phone Number*
3367038681
r Modification (Major or Minor)
r Additional Information
r Residual Annual Report
r High -Rate Infiltration
r Reclaimed Water
r Residuals
r Other
Please provide comments/notes on your current submittal below.
Please attach all information required or requested for this submittal to be review here.
Application Formt Engineering Rans, Specifications, Calculations, Etc.)
westerm pied mont-04162020150418.pdf 8.73MB
upload only 1 RJF document. NLltiple docurrents must be corrbined into one RJF file.

For new and modification permit applications, a paper copy may be required. If you have any questions
about what is required, please contactthe reviewer or Tessa Monday. If a paper --polka*-ion is required,
be advised, applications accepted' far pre -review until both the paper and eIect-c-,i_ co1)ies nave been
received. The paper copy shall include the following:
o Application Form
o All relevant attachments (calcs, soils report, specs, etc.)
o One full-size engineering plan set
o One 11x17" engineering plan set
o One extra set of specifications
o Fee (if required)
MallinE address:
❑iuision of Water Resources1 Division of Water Resources
Non -Discharge Branch I Non -Discharge Branch
1617 Mail Service Center 1 Aft: Nathaniel Thornburg, 91° Floor, Cfice #942W
----------------------------------------------------------- -----------------------------------------
Raleih, NC 27699-1617 512 N. Salisbury St.
Far questions or problems contact Tessa Monday [e-mail] or 919.707.3560.
* W By checking this box I acknowledge that I understand the application will not be accepted
for pre -review until the paper copy (if required) and fee (if required) have been received by
the Non -Discharge Branch. 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).
Signature
Submission Date 4/16/2020

April 16th, 2020
N.C. Department of Environment and Natural Resources
Division of Water Resources
Water Quality Permitting Section — Class B Residuals Permit (DEDICATED)
1617 Mail Service Center
Raleigh, NC 27699-1617
ATTENTION: Mr. Nathaniel Thornburg
REFERENCE: APPLICATION FOR MAJOR MODIFICATION
Synagro Western Piedmont WQ0016247
Dear Mr. Thornburg:
Synagro is submitting this application to modify the referenced residuals land application
permit for the Synagro Western Piedmont Permit.
We are requesting to add 6 new sites and more land to a previous site.
Al-13, AL-15, AL-16, CD-03, 1R-36, RA-53, RA-05
Enclosed is a check for $395.00 to cover the fee associated with a major permit modification.
This application package should contain all information necessary to complete the requested
modification of the Synagro Western Piedmont permit. However, if you require additional
information or have further questions, please contact me at (336-703-8681) or
[e-mail] Thank you in advance for the timely and efficient review of this renewal
application.
Alex Fox
284 Boger Road, Mocksville, NC 27028 • Phone: [phone] • Fax: [phone]

J Synaam Technologies, Inc.
860011673
01/30/2020
'NCOENR-DWQ-APS LAND APPLICATION UNIT (NG NGUI:NK-UVVK
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CKRQ-01222020-RTR
Amount,
395.00
395.00
PLEASE DETACH AND RETAIN FOR YOUR RECORDS
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4 5 Williams Court, Ste 100
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[phone]
NCDENR-DWR
LAND APPLICATION UNIT
1636 MAIL SERVICE CENTER
RALEIGH NC 27699-1636
United States

State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
Division of Water Resources 15A NCAC 02T .1100 — RESIDUALS LAND APPLICATION PROGRAM
INSTRUCTIONS FOR FORM: RLAP 06-16 & SUPPORTING DOCUMENTATION
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 covies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitung Unit
General — This application is for treatment, storage, transport, and/or land application of Class B residuals (may include residuals that
are generated from a water treatment plant or other type facilities) on the proposed or currently approved land application site(s) under
15A NCAC 02T .1100.
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Residuals Land Application Program (FORM: RLAP 06-16) Application: (All Application Packages):
Submit the completed and appropriately executed Residuals Land Application Program (FORM: RLAP 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.
The Applicant's Certification on Page 5 of this form shall be signed in accordance with 15A NCAC 02T .0106(b}. An alternate
person may be designated as the signing official if a delegation letter is provided from a person who meets the criteria in 15A
NCAC 02T .0106(b).
If this project is for a modification of an existing permit, submit one copy of the existing permit.
[] Please submit this application form at Ieast 180 days prior to the expiration date on the existing permit, or 90 days prior to
operation of proposed facility(ies) for application packages involving new or changes to treatment and storage units.
B. Application Fee (New and Major Modification Application Packages)
Submit a check, money order or electronic funds transfer made payable to: North Carolina Department of Environmental
Quality (NCDEQ).
Facility Classification New Permit Major Modification'
Major (land are permitted for > 300 acres) F $1,310 $395
Minor (land are permitted for < 300 acres} $810 $245
1- A major modification shall be defined as any permit modification that: increases the generating facility's residuals dry tonnage;
adds additional land application areas not previously approved for that particular program [including transferring of field(s) from
one program to another]; adds additional residuals sources, or includes the addition of new treatment or storage units/processes not
previously permitted. There is no fee for minor modifications to a permit.
C. Cover Letter (All Application Packages)
0 List all items included in the application package, as well as a brief description of the requested permitting action.
D. Environmental Assessments (May be Required — See 15A NCAC 1 C .0300)
f Submit a copy of the Findings of No Significant Impact (FONSI) or Environmental Impact Statement (EIS). Also, include
information on any mitigating factor(s) from the Environmental Assessment (EA) that impact the construction of the residuals
treatment and storage facilities. An EA may also be required for private systems if any public funds and/or lands are used for
the construction of the subject facilities.
INSTRUCTIONS FOR FORM: RLAP 06-16 Page 1 of 3

E. Operation and Maintenance Plan (New and Renewal Application Packages)
For Modification Application, if there are any changes to the existing plan, submit an updated O&M plan.
Submit the O&M Plan in accordance with 15A NCAC 02T .1 l 10 and include at a minimum:
d Operational functions; describe the operation of the program to show what operations are necessary for the program to
function and by whom the functions are to be conducted.
[] Maintenance schedules; may include equipment calibration, maintenance of signs, etc.
Safety measures; may include safety training program, manuals, signs, etc.
Spill response plan; including control, containment, remediation, emergency contact information, etc.
Inspection plan including the following information;
0 Names and titles of personnel responsible for conducting the inspections.
d Frequency and location of inspections, including those to be conducted by the ORC, and procedures to assure that the
selected location(s) and inspection frequency are representative of the residuals management program.
Ej Detailed description of inspection procedures including record keeping and actions to be taken by the inspector in the event
that noncompliance is observed.
d Sampling and monitoring plan including the following information;
El Names and titles of personnel responsible for conducting the sampling and monitoring.
Detailed description of monitoring procedures including parameters to be monitored.
Q Sampling frequency and procedures to assure that representative samples are being collected. Fluctuation in temperature,
flow, and other operating conditions can affect the quality of the residuals gathered during a particular sampling event. The
sampling plan shall account for any foreseen fluctuations in residuals quality and indicate the most limiting times for
residuals to meet pathogen and vector attraction reduction requirements (e.g. facilities that land apply multiple times per
year but have an annual sampling frequency, may need to sample during winter months when pathogen reduction is most
likely to be negatively affected by cold temperatures.
THE FOLLOWING ADDITIONAL ITEMS (G to M) ARE REQUIRED FOR DEDICATED PROGRAM ONLY.
F. Program Determination
[] Dedicated residuals land application programs are ones in which land application sites meet the criteria in 15A NCAC 02T
.1102(12). Specifically, a residuals land application program is designated as dedicated if any of the following are applicable:
Any land application site certified for the residuals land application program that receives residuals at rates or frequencies
greater than agronomic rates.
Q Any land application site certified for the residuals land application program that is used primarily for residuals disposal,
and agricultural crop production is of secondary importance.
Any land application site certified for the residuals land application program that receives residuals through fixed irrigation
facilities or irrigation facilities fed through a fixed supply system.
Please contact the Non -Discharge Permitting Unit if you need any assistance in determining whether your residuals program
falls under the dedicated program definitions.
G. Program Information
Provide an explanation of why a dedicated system is required instead of a conventional non -dedicated system.
Provide an explanation of the dedicated system and its operation.
H. Detailed Site Maps (All New or Modification Application Packages)
,Submit three (3) sets of standard size plans and two (2) sets of I V by 17" plans (electronic format is acceptable - Adobe PDF
only). For Modifications, submit plans specific to the modification(s) only,
Plans must include the following minimum items:
A general location map, a vicinity map and a topographic map with contours not exceeding 10 feet or 25% of the total site
relief and showing all facility related structures and fences within the land application area.
The location of all wells (including usage and construction details if available), streams (ephemeral, intermittent, and
perennial), springs, lakes, ponds, and other surface drainage features within 500 feet of the land application site(s).
Delineation of the review and compliance boundaries
,Setbacks as required by I5A NCAC 02T .1108
Site property boundaries within 500 feet of all waste treatment, storage, and disposal site(s).
[] A map showing the entire irrigation area with an overlay of the suitable irrigation area depicted by the soil scientist's
evaluation. The irrigation plans shall show each nozzle/emitter and wetted area (when applicable). Clearly label spray
irrigation zones as they will be operated.
[] Plans must depict a completed design and not be labeled with preliminary phrases (e.g., FOR REVIEW ONLY, NOT FOR
CONSTRUCTION, etc.) that indicate that they are anything other than final plans. However, the plans may be labeled with
the phrase: FINAL DESIGN - NOT RELEASED FOR CONSTRUCTION
INSTRUCTIONS FOR FORM: RLAP 06-16 Page 2 of 3

1. Project Evaluation and Receiver Site Management Plan (All New Application Packages or Modifications that include new sites)
El Submit a project evaluation and a receiver site management plan (if applicable) with recommendations concerning cover crops
and their ability to accept the proposed application rates.
J. Hydrogeologie Report (All New Application Packages or Modifications involving increasing the total design capacity)
El Submit a detailed hydrogeologic evaluation in accordance with 15A NCAC 02T J 104(d)(4) and current Division Policy
available at: http:l/www.ncwater.or /g Rules Policies and Regulations/. The document shall be signed, sealed and dated by a
qualified professional.
K. Engineering Design Documents (All New or Modification Application Packages with fixed irrigation facilities or irrigation
facilities fed through fixed supply system)
Submit engineering design documents that have been signed, sealed, and dated by a NC licensed Professional Engineer and/or
Professional Land Surveyor in accordance with 15A NCAC 02T .I 104(d)(2). For Modifications, submit an updated site map
specific to the modification(s) only.
Q The design documents must include the following minimum items:
Q Engineering plans for the facility and equipment except those previously permitted unless they are directly tied into the new
units or are critical to the understanding of the complete process;
Q Specifications describing materials to be used, method of construction, and means for ensuring quality and integrity of the
finished product including leaking testing; and
f Engineering calculations including hydraulic and pollutant loading, sizing criteria, hydraulic profile, total dynamic head
curve analysis for each pump, and irrigation design.
Q Soil mapping units shown on all disposal sites.
L. Water Balance (All New Application Packages or Modifications that include new sites utilizing fixed irrigation facilities or
irrigation facilities fed through fixed supply systems)
Submit a completed and accurate water balance in accordance with 15A NCAC 02T .I 104(d)(5) and current Division Policy
available at: hfpa/www.newater.or /g Rules�Policies and Regulations/.
M. Property Ownership Documentation (All New or Modification Application Packages involving new and/or relocated treatment
or irrigation components)
Property ownership documentation shall consist of one of the following:
f Legal documentation of ownership (i.e., GIS, deed or article of incorporation), or
[J Written notarized intent to purchase agreement signed by both parties with a plat or survey map, or
0 An easement running with the land specifically indicating the intended use of the property and meeting the requirements of
15A NCAC 02L .0107(fl, or
[] A written notarized lease agreement signed by both parties, indicating the intended use of the property, as well as a plat or
survey map.
ONE ORIGINAL AND TWO COPIES OF THE COMPLETED APPLICATION PACKAGE, INCLUDING ALL
SUPPORTING INFORMATION AND MATERIALS, SHALL BE SENT TO THE FOLLOWING ADDRESS:
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
WATER QUALITY PERMITTING SECTION
NON -DISCHARGE PERMITTING UNIT
By U.S. Postal Service:
1617 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1617
TELEPHONE NUMBER: [phone]
By Courier/Special Delivery:
512 N. SALISBURY STREET
RALEIGH, NORTH CAROLINA 27604
FAX NUMBER: [phone]
INSTRUCTIONS FOR FORM: RLAP 06-16 Page 3 of 3

State of North Carolina
Department of Environmental Quality
Division of Water Resources
v s on of Water Resources 15A NCAC 02T .1100 —RESIDUALS LAND APPLICATION PROGRAM
FORM: RLAP 06-16
I. APPLICANT INFORMATION:
1. Applicant's name: S na ro Western .Piedmont Class B Permit
Applicant type: 0 Individual Corporation Q General Partnership [ Privately -Owned Public Utility
Federal Q. State 0 Municipal County
Signature authority's name per 15A NCAC 02T A 106: Robert Roth Title: TSS Manager
Applicant's mailing address; 284 Boger Rd
City: Mocksville State: NC Zip: 27028
Telephone number: (336-403-4324) Email Address: rroth(a Wagro.com
2. Consultant's name: Alex Fox License Number (for P.E.):
Affiliation: 0. On Staff 0 Retained (Firm: S na ro Central LLC.)
Consultant's mailing address: 284 Bo eg r Rd
City: Mocksville State: NC
Zip: 27028
Telephone number: 336 703-8681
Email Address: afox s na ro.com
3. Agronomist's name:
License Number.
Affiliation: [] NIA 0 On Staff
, El Retained (Firm: }
Agronomist's mailing address
City: State: NC
Zip:
Telephone number: (_) '_
Email Address
4. Soil Scientist's name: Chris Murray
License Number: 1284
Affiliation: 0 N/A [] On Staff
0 Retained (Firm: `)
Soil Scientist's mailing address:: 216 S. Swing Rd. Suite I
City: Greensboro State: NC
Zip: 27028
Telephone number: 336) 662-5487 Email Address: chris(cr�piedmontsoil.com
5. Fee submitted [ (See Instruction B)
II. PERMIT INFORMATION:
1. Application is for (check all that apply): ❑ new, 0 modified, [] renewed permit
2. If this application is being submitted to renew or modify an existing permit, provide the following:
Permit number: WQ0016247
Date of most -recently issued permit: November 17, 2017
Date of most -recently certified Attachment A (if different than the permit):
Date of most -recently certified Attachment B (if different than the permit): I
FORM: RLAP 06-16 Page 1 of 5

III. RESIDUALS LAND APPLICATION PROGRAM INFORMATION:
I. Residuals Processing Facility's physical address: Source S12ecific
City: -State: NC Zip: 28658
Coordinates: Latitude: Longitude:
Datum: NAD83 Level of accuracy: Map
Method of measurement: Second
2. County where residuals land application program is headquartered: Catawba
3. List the Operator In Responsible Charge (ORC) and all Back -Up ORCs for the residuals land application program, their
certification numbers, and their affiliations in the following table:
Designation
Name
Affiliation
Certification Number
ORC
Robert Roth
Synagro
1001672
Back -Up ORC
Adam Brigman
Synagro
1006653
Additional Back -Up
ORCs
(if applicable)
If an ORC and at least one Back -Up ORC are not currently designated for this residuals land application program, provide the
candidates' names, affiliations, and an estimated time schedule for each candidate's completion of the required training school
and certification test: Alex Fox Spring 2020
4. Complete the following tables regarding management of the residuals land application program:
a. Plant Available Nitrogen Summary: Determine the maximum plant available nitrogen (PAN) generated by all residuals
source -generating facilities as currently certified and proposed for certification with this application and list the results in the
following table:
Maximum amount of residuals to be certified: Source SpedrIC dry tons per year.
PAN
Pounds of PAN per Dry Ton
(Weighted Average)
Pounds of PAN per Year
,Surface
Incorporation
or Injection
Surface
Incorporation
or Injection
First -Year
Five -Year Maximum Adjusted
b. LandApplieation Site Use Summary: Summarize information regarding the land application sites as currently certified and
proposed for certification with this application:
Category
Use
Acres
Comments
Crops
Forest or Plantation
0
Row Crops
369
Hay
350.3
Pasture
264.3
J
Total:
983.6
Methods
Surface
983.6
Incorporation or Injection
0
Total:
983.6
FORM: RLAP 06-16
Page 2 of 5

c. Residuals Land Application Summate: Determine the minimum acreage required to Iand apply the residuals as currently
certified and proposed for certification assuming the scenarios listed in the following table: Source Specific
Assumed
Application Rate
(Ibs PAN/ac yr)
Acres Required Using
First -Year PAN Concentrations
Acres Required Using
Five -Year Maximum Adjusted PAN
Concentrations
Surface
Incorporation or
Injection
Surface
Incorporation or
Injection
50
100
150
200
6. If applicable, provide a plan and a schedule to resolve any known issues that would prevent land application of the proposed
residuals due to the violation of North Carolina Administrative Code (e.g. not enough storage, not enough land, vector reduction
practices not in place, etc.): 3
7. Specify type of residuals program (See Instruction F): 0 Non -dedicated Q Dedicated
If Dedicated, specify the following (check all that apply):
Q Residuals program contains any land application site(s) that receives residuals at rates or frequencies greater than agronomic
rates, explain, I
Residuals program contains any land application site(s) that is used primarily for residuals disposal, and agricultural crop
production is of secondary importance, explain;
El Residuals program contains an land application sites that receives residuals through fixed irrigation facilities or irrigation
P �' � Y pp� {)..
facilities fed through a fixed supply system, explain
IV. RESIDUALS SOURCE INFORMATION: (Required for all new, renewed, or modified residuals source)
Complete and submit the following Residuals Source Certification and all associated documentation.
H
Residuals Source
Certification
V. LAND APPLICATION SITE INFORMATION: (Required for all new, renewed, or modified Iand application site)
Complete and submit the following Land Applications Site Certification and all associated documentation.
Land Application SHte
Certification. doc
FORM: RLAP 06-16 Page 3 of 5

Note: Item VI. Applicable to Dedicated Program with fixed irri ation system only.
VI. DESIGN INFORMATION FOR FIXED IRRIGATION SYSTEM
1. The irrigation system is: Q Spray 0 Drip
2. Disposal system is: existing proposed.
3. Minimum depth to mean seasonal high water table (SHWT) within irrigation sites(s) per Soil Scientist's Evaluation ; ~ . feet
below ground surface. Rules 15A NCAC 02T .0505(nl requires at least one -foot vertical separation between SHWT and ground
surface.
4. Are there any artificial drainage or water movement structures within 200 feet of any irrigation area?
[J Yes or Q No If Yes, please explain if the soil scientist report addresses artificial structures and please indicate if
structures are to be maintained or modified
5. Loading rates recommended by the Soil Scientist Evaluation:
6. Design loading rates are equal or less than the loading rates recommended by Soil Scientist?
0 Yes or Ll No If No, explain why 15A NCAC 02T .0505(n) is not met '
7. Non -dedicated System Design (fill in the appropriate information for either a spray or drip irrigation system):
Spray Irrigation Design Element Plan Sheet Specification
Number Page Number
Wetted diameter of nozzles ft
Wetted area of nozzles it2
Nozzle capacity gpm E
Nozzle manufacturer 1 model 1 ~ ; i
Elevation of highest nozzle __rv� � ` ,.,�
;z
FORM: RLAP 06-16 Page 4 of 5

Applicant's Certification (signing authority must be in compliance with I5A NCAC 02T .0106):
The applicant or any affiliate has not been convicted of an environmental crime, has not abandoned a wastewater facility without proper
closure, does not have an outstanding civil penalty where all appeals have been exhausted or abandoned, are compliant with any active
compliance schedule, and do not have any overdue annual fees under Rule 15A NCAC 02T .0105.
ED Yes 0 No, Explain, ' l
(Signature Authority's Name — PLEASE PRINT) (Title)
attest that this application for I/ ,t'
(Facility Name)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that the Division of Water Resources
may not conduct a technical review of this program and approval does not constitute a variance to any rules or statutes unless specifically
granted in the permit. Further, any discharge of residuals to surface waters or the land will result in an immediate enforcement action,
which may include civil penalties, injunctive relief, and/or criminal prosecution. I will make no claim against the Division of Water
Resources should a condition of this permit be violated. I also understand that if all required parts of this application are not completed
and that if all required supporting information and attachments are not included, this application package will be returned to me as
incomplete.
Note: In accordance with North Carolina General Statutes § 143-215.6A and § 143-215.613, any person who knowingly makes any false
statement, representation, or certification in any application shall be guilty of a Class 2 misdemeanor, which may include a fine not to
exceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature: Date: z-v
FORM: RLAP 06-16 Page 5 of 5

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
LAND APPLICATION SITE CERTIFICATION
INSTRUCTIONS FOR FORM: LASC 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 information, visit the Water Quality Permitting Section's Non-Dischar e Permittin Unit
General — This certification provides detailed information of receiving sites for land application of Class B residuals (may include
water treatment plant or other type residuals) in accordance with 15A NCAC 02T .l 100. Do not submit this certification for review
without a corresponding application form (FORM: RLAP 06-16 or FORM: SDR 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Application Site Certification (FORM: LASC 06-16):
® Submit the completed and appropriately executed Land Application Site 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.
❑ For new or renewed permits, submit the requested information for all land application sites.
® For modified permits, submit the requested information for only those sites that are new, transferred or affected by the
proposed modification.
B. Land Application Site Information:
® The status of the land application site with respect to this residuals land application program must be provided in table I. The
status categories and their corresponding codes are as follows:
1 New (N) ♦ Renewed (R) ♦ Modified (M) ♦ Transferred (T) ♦ Deleted (D)
® Attach the following in accordance with each status code:
Status Code
Required Item
N
R
T
M
County Board
✓
Notification. doc
H
Land Owner
✓
✓
Agreement
(If applicable)
4+s__
✓
✓
✓
✓
Setback Waiver
Agreement
An updated vicinity/setback map in accordance with the "Map Guidance
for Residuals Land Application Permits"
✓
✓
✓
A soils and agronomic evaluation in accordance with the "Soil Scientist
✓
Evaluation Policv"
INSTRUCTIONS FOR FORM: LASC 06-16 Page I of 3

An updated accounting of the land application site's cumulative ✓
pollutant loading rates (CPLRs)
Required Item
Status Code
N R T M
For previously permitted sites without a soil series name indicated in the
Attachment B, submit County Soil Survey Map (or equivalent) clearly ✓ V
indicate the location of the land application site and in accordance with
the soil map requirements in the "Soil Scientist Evaluation Pnlicv"
Acknowledgement of field transfer from Land Owner (Fields may not 1
be permitted to multiple Permittees over the same timeperiod)
* This item may be required for land application site with a status code "M", please contact the Division if you need assistant in
determining attachment requirements.
® Crop Type should include the most likely crop types for the life of the permit (five years).
® Predominant Soils Series Name must be either the name of the soil indicated in Attachment "B" of the existing permit, or
name of the soil series as provided by the licensed soil scientist.
® Predominant Soil Mapping Unit or Representative Slope: Either the Soil Mapping Unit or the representative slope of each
site must be provided. The predominant soil -mapping unit must be consistent with the predominant soil series name. Please
note that the soil mapping units are variable between Counties, so care should be taken in properly identifying the correct
mapping unit. If a representative slope is provided, it must be determined accordingly:
® For sites previously permitted for use, but do not have an established soil mapping unit (the mapping unit provides
information on both the soil series name and the slope of the soil), the Applicant may determine the representative slope
by using the average slope provided in the County ,Soil Survey (or equivalent). A soil type with a slope range of 4 - 8%
would have a representative slope of 6%.
® New Sites to be permitted must have slopes determined as part of the soils report prepared by a licensed soil scientist.
® Acceptable methods for determining location coordinates (i.e., Iatitude and longitude) and their corresponding codes are as
follows:
• Address Matching (ADD) • Digital or Raw Photo Extraction (EXT)
• Aerial Photography with Ground Control (AER) • Geodetic Quality GPS Survey (GEO)
• Cadastral Survey (SUR) • LORAN-C Navigation Device (LOR)
• Conversion from Coordinate Plane (CP) • Navigation Quality GPS (GPS)
• Conversion from Township -Section -Range (TSR) a Remote Sensing (RS)
• Conversion from Universal Trans Merc (UTM) • Zip Code Centroid (ZIP)
• Map Interpretation by Digital or Manual Extraction (MAP)
C. Waterbody and Classifications Information: (new sites only)
® Use an 8.5 by 11-inch copy of the portion of a 7.5-minute USGS Topographic Map to identify the location where the
residuals program activities are planned to occur as well as the closest downslope surface waters as clearly as possible. Each
map portion must be labeled with the map name and number, the identified location, and be of clear and reproducible quality.
® Surface water body classifications information may be found at: hgp://deq.nc.aov/about/divisions_/water-
resources/ lannintr classification-standards/classifications
® Any questions concerning the waterbody and its classification, please contact the Division's regional offices.
® A Iist of the Division's regional offices, their county coverage, and their contact information may be downloaded at:
hitp://deq.ne.aov/contact/regional-offices
® GeneraI Instructions: There are 17 river basins in North Carolina. Each basin has associated waterbodies with assigned
subbasins, location descriptions, stream index numbers and established classifications.
1. Identify the project area on a 7.5 minute USGS topographical map (an 8.5 x 11-inch sheet showing the project area
should be submitted with the permit application regardless of whether a Stream classification was completed).
2. Determine the names of all the closest down slope surface waters from the project site. For unnamed tributaries, see
Table l: Unnamed Tributaries Entering Other States or for Specific Basin Areas. Label any unnamed tributaries as
"UT to stream name" as the waterbody name.
3. Open the link htt /p /deq.nc.gov/about/divisions/water-resources/ lap nnin /g/classification-standards/classifications.
® Stream Classification Process: One of the options below may be used depending on the known initial project information.
® KNOWN BASIN WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
1. Select proper basin from the List all Waterbodies in Basin sorted report. Sort hydrologically as this will provide
the proper Iocation descriptions if multiple runs.
INSTRUCTIONS FOR FORM: LASC 06-16 Page 2 of 3

2. Locate the name of the identified waterbody (from General Directions) on the Iist.
3. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream. point).
4. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
❑ KNOWN COUNTY WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
1. Select the proper county from the List all Waterbodies in county, hydrologically report.
2. Locate the name of the identified waterbody (from General Directions) on the list.
3. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream point).
4. Record all Basins, Stream Index Numbers and CIassifications applicable to the project.
❑ UNKNOWN BASIN WHERE CLOSEST DOWN SLOPE SURFACE WATER IS LOCATED
1. Use the Clickable basin map to hydrologically sorted list report.
2. Click on the approximate project location to bring up the hydrologically sorted list.
3. Locate the name of the identified waterbody (from General Directions) on the list.
4. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream point).
5. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
❑ Notes on index number and unnamed streams:
Unnamed Streams 15A NCAC 02B .0301 M.
❑ Any stream which is not named in the schedule of stream classifications carries the same classification as that assigned
to the stream segment to which it is tributary (at the point of entry) except:
(A) unnamed streams specifically described in the schedule of classifications;
(B) unnamed freshwaters tributary to tidal saltwaters will be classified "C"; or
(C) after November 1, 1986, any newly created areas of tidal saltwater which are connected to Class SA waters by
approved dredging projects will be classified "SC" unless case -by -case reclassification proceedings are conducted.
❑ The following river basins have different policies for unnamed streams entering other states or for specific areas of the
basin:
Unnamed Tributaries Entering Other States or for Specific Basin Areas
Hiwassee River Basin
Streams entering Georgia or Tennessee shall be classified "C Tr."
Little Tennesse River
Basin And Savannah
River Drainage Area
Streams entering Georgia or Tennessee shall be classified "C Tr." Such streams in the Savannah
River drainage area entering South Carolina shall be classified "B Tr."
French Broad River
Basin
Streams entering Tennessee will be classified "B."
Watauga River Basin
Streams entering the State of Tennessee are classified "C."
Broad River Basin
Streams entering South Carolina are classified "C."
New River Basin
Streams entering the State of Tennessee are classified "C."
Catawba River Basin
Streams entering South Carolina are classified "C."
Yadkin -Pee Dee River
Basin
Streams entering Virginia are classified "C," and such streams entering South Carolina are
classified "C."
Lumber River Basin
Streams entering South Carolina are classified "C Sw."
Roanoke River Basin
Streams entering Virginia are classified "C." Except that all backwaters of John H. Kerr
Reservoir and the North Carolina portion of streams tributary thereto not otherwise named or
described shall carry the classification "B," and all backwaters of Lake Gaston and the North
Carolina portion of streams tributary thereto not otherwise named or described shall carry the
classification "C and B."
Chowan River Basin
Streams entering Virginia are classified "C."
Tar -Pamlico River
Basin
All drainage canals not noted in the schedule are classified "C Sw." except the main drainage
canals to Pamlico Sound and its bays which shall be classified "SC."
Pas uotank River Basin
All drainage canals not noted in the schedule are classified "C."
INSTRUCTIONS FOR FORM: LASC 06-16 Page 3 of 3

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OPERATIONS AND MAINTENANCE PLAN
SYNAGRO RESIDUALS LAND APPLICATION FOR WQ0016247 (Synagro Western Piedmont RLAP)
Inspection Plan
Inspections will be conducted on a weekly basis at the land application site during activities of the project. Inspection
frequency is based on the time frame to complete the project and the amount of dry tons to be land applied from the
facility. In all cases, fields shall be inspected during application or within 48 hours following application. The inspections
will consist of inspecting a current field that is being applied as well as inspecting random fields that have been completed.
These inspections will consist of:
1. Verifying that the "Pre -Operations Check List" has been completed and signed by both operational and technical
staff.
2. Checking the calculated loads to insure the correct amount of residuals are being land applied.
3. Insuring that all manned equipment has a copy of the spill control plan, the permit, and the operations and
maintenance plan.
4. Insuring that the field has been flagged properly and that all buffers are being adhered to.
S. Insuring that the "Crop and Landowner Verification" form has been filled out.
6. Verifying that the residuals have been adequately sampled to confirm compliance.
The records will be kept in the project files in the respective office for the project. The Permittee or Inspector shall report
by telephone to the NCDENR/DWR Mooresville Regional Office at 704-663-1699, as soon as possible, but no later than 24
hours after, or the next working day, following the occurrence or first knowledge of the occurrence of the following.
• Any occurrence with the distribution program resulting in the land application of significant amounts of
material that is abnormal in quantity or characteristics.
• Any failure of the distribution system that results in the release of material to surface waters.
• Any time that self -monitoring information indicates that the facility has gone out of compliance with the
permit.
• Any process failure that results in the system not adequately treating the residuals.
• Any spill or discharge from a vehicle or piping system during residuals transportation.
Any release that requires immediate reporting outside of normal business hours shall be called in to DENR at 800-662-
7956, 800-858-0368, or 919-733-3300. These numbers are to be called in the event of a release to surface waters or
imminent failure of a storage system when the event occurs outside of normal business hours. Within 5 days of the first
notice of an occurrence, a written response in the form of a letter shall be sent to DENR outlining the actions taken or
purposed actions taken to ensure that the problem does not recur.
Persons responsible for inspections on this project are as follows:
Robert N. Roth, Technical Services Manager or his designee

OPERATIONS AND MAINTENANCE PLAN
SYNAGRO RESIDUALS LAND APPLICATION FOR WQ0016247
Sampling Plan
Sampling for this project consists of sampling the residuals prior to each land application event. The chart at
the bottom of Attachment A provides a listing of required sampling, based on the dry tonnage applied from
each individual WWTP. Based on the recent dry tonnage applied, each plant will need to be sampled either
once or four times per year.
The residuals shall be sampled annually for the following: (Regulatory level in milligrams per liter in parentheses.)
Arsenic (5.0)
1, 4-Dichlorobenzene (7.5)
Nitrobenzene (2.0)
Barium (100.0)
1, 2-Dichloroethane (0.5)
Pentachlorophenol (100.0)
Benzene (0.5)
1,1-Dichloroethylene (0.7)
Pyridine (5.0)
Cadmium (1.0)
2, 4-Dinitrotoluene (0.13)
Selenium (1.0)
Carbon tetrachloride (0.5)
Endrin (0.02)
Silver (5,0)
Chlordane (0.03)
Hexachlorobenzene (0.13
Tetra ch loroethyl ene (0.7)
Chlorobenzene (100.0)
Heptachlor (and its hydroxide) (0.008) Toxaphene (0.5)
Chloroform (6.0)
Hexachloro-1,3-butadiene (0.5)
Trichloroethylene (0.5)
Chromium (5.0)
Hexachlorethane (3.0)
2,4,5-Trichlorophenol (400.0)
M-Cresol (200.0)
Lead (5.0)
2,4,6-Trichlorophenol (2.0)
o-Cresol (200.0)
Lindane (0.4)
2,4,5 TP (Silvex) (1.0)
p-Cresol (200.0)
Mercury (0.2)
Vinyl Chloride (0.2)
Cresol (200.0)
Methoxychlor (10.0)
2,4-D (10.0)
Methyl ethyl ketone (200.0)
The residuals will also be sampled based on the chart below for the following constituents
Dry Tons Generated
(short tons per year)
Monitoring Frequency
(Established in 40 CFR 503 and 15A NCAC 02T.1111)
<319
1 time per year
=>319-<1,650
1 per Quarter (4 times per year)
=>1,650-<16,500
1 every 60 days (6 times per year)
=>16,500
1 every month (12 times per year)
Aluminum
Ammonia -Nitrogen
Arsenic
Cadmium
Calcium
Copper
Lead
Sodium Adsorption Ratio (SAR)
Magnesium
Mercury
Molybdenum
Nickel
Nitrate -Nitrite Nitrogen
Phosphorous
Potassium
pH
Plant Available Nitrogen (calculation)
Selenium
Sodium
Total Solids
Total Kjeldahl Nitrogen
Zinc
In order to meet pathogen requirements, the material from each plant will be sampled for fecal coliform density. The
means to verify vector attraction reduction monitoring requirements will vary based on each plant. For the City of
Statesville's WWTP's, the residuals will be tested using the specific oxygen uptake rate. For the West Stanly WWTP and
Norwood WWTP, the requirements will be met through the material passing a 30 day bench scale test. The samples that
will be pulled for the TCLP, nutrient and metals sample, and fecal coliform density will be taken from the storage areas of
each plant. In contrast, for the City of Statesville's WWTP's, the SOUR samples will be taken prior to belt -pressing the
residuals. Samples collected for nutrients/metals analysis and TCLP/RCI will be composite samples. The following people
are responsible for sampling:
Robert N Roth, Technical Services Manager or his designee.

SPILL RESPONSE PLAN
PROJECT: SYNAGRO WESTERN PIEDMONT PERMIT W 0016247
IN THE UNLIKELY EVENT OF A SPILL THE FOLLOWING ACTIONS SHALL BE TAKEN
IMMEDIATELY:
1. MANAGEMENT OF SPILL CLEAN-UP ACTIVITIES:
The Synagro Operations Manager shall take immediate charge and initiate clean-up activities. Synagro labor and
equipment is to be utilized. In the event additional labor and equipment is required, assistance may be requested from the
NC Department of Transportation, and other private contractors as necessary.
2. HALT THE SOURCE OF THE SPILL:
Such as a ruptured container or damaged transport unit.
3. CONTAIN THE SPILL:
Form a barrier. Sufficient quantities of straw shall be used for such purposes. Earthen barriers may be constructed to
augment the straw bale containment area of the spill. The Synagro Operations Manager or the person in charge on the
spill site will advise the clean-up personnel where to get the straw, lime, and other items necessary to complete the clean-
up operation, i.e., local farmers, farm supply centers, nurseries, etc.
4. CLEAN-UP:
Employ front-end loaders, vacuum equipment, sludge application vehicles, and/or local septic tank service to remove as
much of the spilled material as possible. Straw and/or sand should be scattered in the spill area to soak up the remaining
material. The straw- and sand -soaked material will be collected and removed to a disposal area approved by
representatives of the state regulatory agency.
5. FINAL CLEAN-UP-
Employ rotary brush sweeper if needed, and apply lime to the spill area upon the approval of the clean. -up efforts by the
state regulatory representative. If the event occurs on private property, the clean-up will be completed to the satisfaction
of the property owner and state regulatory representatives. The ultimate goal will be to restore the spill area to its original
condition if possible.
6. NOTIFICATION:
As soon as possible after the spill occurs, the Synagro Operations Manager or assistant will notify the Synagro Central
office, and they will then be responsible for notifying other key Synagro personnel.
7. REPORTING:
Synagro Central personnel will notify the Mooresville Regional office at [phone] as soon as possible, but not more
than 24 hours after, or on the next working day following the occurrence. The Operations Manager shall provide a written
report within 48 hours of the spill to the Technical Services Director. The report shall list all relative information and
actions taken. Synagro Central personnel will file a written report to the Mooresville Regional office of the NCDENR
within 5 days of the occurrence. For after hours reporting the Division's emergency number shall be called to report all
incidences (1-800-858-0368) or (919-733-3300).

SYNAGRO, WESTERN PIEDMONT CLASS B PERMIT
WQ 0016247
SOIL SCIENTIST CERTIFICATION
This is to certify that soil profile evaluations were conducted on the proposed application
sites for the Western Piedmont project by Piedmont Environmental Associates, P.A. on
behalf of Synagro Central, LLC. The evaluations consisted of hand auger borings and
descriptions of the soils on the application sites. All hand auger borings included in this
package were either performed by me or under my direct supervision. All other work
performed for this permit application was conducted by Synagro Central, LLC.
G. Christopher Murray, L.S.S.
No. 1284
Synagro, Western Piedmont WWTP Project, Various Fields

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SYNAGRO, WESTERN PIEDMONT CLASS B PERMIT
WQ 0016247
SOIL SCIENTIST CERTIFICATION
This is to certify that soil profile evaluations were conducted on the proposed application
sites for the Western Piedmont project by Piedmont Environmental Associates, P.A. on
behalf of Synagro Central, LLC. The evaluations consisted of hand auger borings and
descriptions of the soils on the application sites. All hand auger borings included in this
package were either performed by me or under my direct supervision. All other work
performed for this permit application was conducted by Synagro Central, LLC.
G. Christopher Murray, L.S.S.
No. 1284
Synagro, Western Piedmont WWTP Project, Various Fields

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Q�J N N N U U N N N
J

State of North Carolina
D. Department of Environment and Natural Resources
W. R
Division of Water Resources
Dlvlslon 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 ilicant shall submit one on final and two co ies of the goplication and
supporting documentation
For more information, visit the Water Quality Permitting Section's Nan-Dr.'schar e Permitten Unit
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 submit this agreement for review without a corresponding application form (FORM: RLAP 06-16). 1100. Do not
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. La Owner Agreement (FORM: LOA 06-16):
Submit the completed and appropriately executed Residuals Source Certification FORM:
LASC 06-16) form, Pleasemake any unauthorized content changes to this form. If necessary for clarity or due to spacerestrictions, attachments not
the
plicat'on 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 b
A plicant. p y an entity other than the
[A copy of the completed and appropriately executed agreement must be provided to the landowner and the Iessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
AppIicant's name:
hereinafter
application
Agreement:
f
referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
sitc(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Tease Land Use or Residuals Source
Site/Field ID Special note
(yes/no) Cropping Patterns Intended Use of Crops
(optional) (no-till/over-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
Page 1 of 3

I. STIPULATIONS:
L The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s) specified by this Agreement.
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 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 I1) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWI2, 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 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 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 pH of the soil, residuals and lima 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
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 site(s) by the Permittee, the landowner, or
his representative prior to and during a residuals land application event.
H. The landowner or his representative hereby authorizes the Permittee, 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
copy any records
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the perm
that must be kept under the terms and conditions of the permit; take necessary leachate, term of, and 12 months after termination of, this Agreement. surface water, groundwater, or soil samples during the
II. RESTRICTIONS:
L 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 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. Turf grown on land where residuals are applied shall not be harvested for a I2-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 0105(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 mark one of the following;
❑ A re -defined compliance boundary is needed for field(s) ID:
(Please include the rationale for the requested re -location of the compliance boundary and attach a map showing the newly proposed
compliance boundary to the application package)
A re -defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
❑ The land application field(s) ID:
residuals land application program; Permit Number WQ: is currently permitted under another
agreement, he/she is requesting that the #ield(s) be removed from the previously permitted residuals and herebyer acknowledge
ci titianprogram that by and signtraning
i
e land own
into the new program;
(Name of the new program)
FORM: L,OA 06-16
Page 2 of 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: Ifs 1%�/t�GC
Address:
City: 'ice Auc State: Zip:
t 1�
Phone: 7 .—E-mail address:
Signature.'-, lld4�u,
� � - Date:
NORTH CAROLINA, k, x n bCOUNTY j
I, the undersigned Notary Public do hereby certify that A 10 ? 4
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
%%IIIIIIIIJ, IPA
WITNESS my hand a official seal this the � �{ � lill O �
day of f y sry
20 ++
J C7
v Signature and seal: �• Z
My commission expires:
Lessee's/Operator's Certification:
�v
.F� C
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 n b
Signature: /�- Date:
FORM: LOA 06-16 Page 3 of 3

APPLICATION MAP
LEGEND
APPLICATION AREA
PRIVATE ROAD
STREAM
FIPITITIrki
X X X FENCE
PROPERTY LINE
UNSUITABLE AREA
WATER
ONSITE HOUSE
OFFSITE HOUSE
OUTBUILDING
WELL
SOIL BORING
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area, The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
GRAPHIC SCALE
1 " = 660'
660' 0 660,
NC-AL-1 3
Fields 4-5

APPLICATION MAP
I art=nln
APPLICATION AREA
F01
UNSUITABLE AREA
— — — — — — PRIVATE ROAD
WATER
— — — — STREAM
®
ONSITE HOUSE GRAPHIC SCALE
-- DRAIN
,..
OFFS171=HOUSE ,
X FENCE
OUTBUILDING 660, 0 660'
PROPERTY LINE
WELL
SOIL BORING
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within NC -AL- 3
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All -
locations are approximate. Field 6

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SOIL StIR1/Fv
GRAPHIC SCALE
1"=660'
660` 0 660,
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area, The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
NC-AL-13
. � h

TOPOGRAPHIC MAP
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s' �, r� 'w:' � a .a s � � 'r�' �f 4' w�rr rc •5 Yes Hsu,:
' s am � - '�" t <a r - � �'�z �"'�. >• ��� x` • _ b 9��^ �%.q,� 3`�' � qf'3 ,�'�ti�'�
yr It.
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GRAPHIC SCALE
1 ° = 660'
660, 6 660'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
NC-AL-13
Field 6

TOPOGRAPHIC MAP
GRAPHIC SCALE
V=800'
aoo, o 800,
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within NC-AL-1 3
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate. Fields 4-5

VICINITY MAP
GRAPHIC SCALE
1" = 4,000'
4,000' 0 4,000'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
N C-AL-13
Fields 4-6

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State of North Carolina
Department of Environmental Quality
Division of Water Resources
b[vision of Water Resources COUNTY BOARD NOTIFICATION
INSTRUCTIONS FOR FORM: CBN 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 information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit
General — This notification is intended to provide the county board in which the land application site is proposed to be located with
general information on the size, location and type of residuals land application proposed to occur in their county, and to give them an
opportunity to comment on the pending permitting request as stipulated in Session Law 2013-340. Notification is not required for
fields deemed permitted to receive Class A residuals under 15A NCAC 02T .1100. Do not submit this document for review
without a corresponding residuals program application form (FORM: RLAP 11-15).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. County Board Notification (FORM: CBN 11-15):
® Submit the completed and appropriately executed County Board Notification (FORM: CBN l 1-15). Please do not make any
unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to the form may
be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
® Prepare a separate County Board Notification (FORM: CBN 11-I5) for each county in which the proposed land application
sites are located.
B. Critical Watershed Areas Information:
® Under 15A NCAC 02B .0212, no new permitted sites for land application of residuals are allowed within critical watershed
areas. It is the AppIicant's responsibility to ensure that the proposed land application sites are not located within these areas.
® For more information regarding Water Supply Watershed Protection Program, please visit the Division website at:
htt )s://deg.nc. gov/about/divisions/water-resources/water-resources-rules/water-supply-watershed-protection-program
❑ If uncertain about whether the proposed sites are located within the critical areas, contact the Division or call [phone].
C. Notification Package Submission:
❑ Complete and mail the notification letter, source facility summary, land application site summary, and site location maps to
the appropriate County Board by certified mail with a return receipt requested. It is recommended that a copy of the
notification package also be sent to the County Manager.
❑ The most current publication of the Directory of State and County Officials may be downloaded at:
https://www.sosne,gov/vubIications/direct.gNx
❑ A list of the Division's regional offices, their county coverage, and their contact information may be downloaded at:
hgp://deg.nc.gov/contact/regional-offices.
❑ The source facility summary shall include: facility name; county where it is located; and the proposed annual dry tannage
(i.e., a copy of "Residuals Source Facility Summary" is adequate but not required).
❑ The land application site summary shall include: field ID; acreage; county where it is located; latitude and longitude (i.e., a
copy of "Land Application Site Certification" is adequate but not required).
D. Proof of Submission:
❑ Attach an 8.5 by 11-inch copy of the return receipt to the back of this attachment prior to submission of the application to the
Division for review.
INSTRUCTIONS FOR FORM: CBN 06-16 Page 1 of 1

North Carolina Department of Environmental Quality
Pat McCrory Donald R. van der Vaart
Governor Secretary
Date: 04/13/2020
Name of Chairman to the Board of County Commissioners: Ryan Maybes
Complete mailing address: 621 Liledoun Rd
City: Taylorsville State: NC Zip: 28681
County where Iand application sites are located: Alexander
From: Applicant's name: Synag;ro Western Piedmont for Statesville Waste Water (on behalf of the Division of Water
Resources in accordance with Session Law 2013-340)
Contact person and title: Alex Fox
Complete mailing address: 284 Boger rd
City: Statesville
Telephone number: [phone]
State: NC Zip: 27028-h�;s�"
E-mail address: [e-mail]
Subject: Notification of residual land application site proposal
This is to notify you that the Applicant listed above will be submitting an application to the Division of Water
Resources for the land application of residual solids to site(s) located in your county. During this review, the Division
will ensure that all federal and state regulations are enforced. Attached to this form is information regarding residuals -
generating sources and locations of the proposed land application sites. Please forward this letter and its associated
attachments to the appropriate Department within your County (i.e., Health or Environmental Health Department and
Planning Department) if applicable.
More information of the land application sites included in this application will be available at the following
Division of Water Resources Regional Office:
Name of appropriate regional office: Mooresville Regional Office
Complete mailing address: 610 East Center Avenue Suite 301
City: Mooresville State: NC Zip: 28115
Telephone number: (704-235-2184)
Expected date of application submission: 04/15/2020
Should you desire to comment on this application, please do so no later than 30 calendar days following the
expected application submission date. If you have any questions or comments about this notification, or if you would like
more information, please contact the appropriate regional office at the telephone number provided above. Thank you in
advance for your attention to this matter.
Enclosures: Source Facility Summary
Land Application Site Summary
Maps
Non -Discharge Permitting Unit
1617 Mail Service Center, Raleigh, North Carolina 27699.1617
Phone: 91H07-64641Internet: htto://Portal.nr-denr.oa/webfwa
An Equal Opportunity 1Affirmative Action Employer— Made in part with recycled paper FORM: CBN 06-16

Alex Fox
From: UPS Quantum View <[e-mail]>
Sent: Tuesday, April 14, 2020 9:14 AM
To: Alex Fox
Subject: UPS Delivery Notification, Tracking Number 1Z51 F78WO101154909
Hello, your package has been delivered.
Scheduled Delivery Date: Tuesday, 04/14/2020
Estimated Delivery Time: End Of Day
Left At: INSIDE DELIV
Signed by: LINDA
SYNAGRO - MOCKSVILLE
INSIDE DELIV
Tracking Number:
Ship To:
Number of Packages:
UPS Service:
Package Weight:
Reference Number.
Q Download the UPS mobile aaa
USIEZOW0101154909
621 LILEDOUN RD
TAYLORSVILLE; NC 28681
US
0
UPS Next Day Air@
0.05 LBS
20-2360-30-60-4310 50-0055
© 2020 United Parcel Service of America, Inc. UPS, the UPS brandmark, and the color brown are
trademarks of United Parcel Service of America, Inc. All rights reserved.
All trademarks, trade names, or service marks that appear in connection with UPS's services are the
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101

State of North Carolina
BU&I 1W Department of Environmental Quality
J WT ZML Division of Water Resources
4 ,; ,,; w
' Division of Water Resources 15A NCAC 02T .1100 — 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 information, visit the Winter Quality Permitting, Section's Non-DischargePermitting Unit.
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):
Qe"Submit the completed and appropriately executed Land Application Site 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 Iong as the attachments are numbered to correspond to the section and item to which they
fer.
I� Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
pplicant.
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: ArL.,5r �P �
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)
(Y )
Land Use or
Cropping Patterns
PP� g
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
-15�-
r1D,J ua 3
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 I of 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 Iand 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. , .0 f ,
Landowner name:
Address:
City: i
Phone:
Signature:
State: ��`_ Zip:
E-mail
NORTH CAROLINA, COUNTY %�
I, the undersigned Notary Public do hereby certify that 4r AWN �*� � ��nQ� r
personally appeared before me this day and acknowledged the due execution of the forgoing instrument. gtNlllj10�
WITNESS my hand and official seal this the SI` '�,� 1M F6��-to
day of OCA.0d-r r' , 20
Signature and seal:
My commission expires: —Jai 77., 204 Vk
Lessee's/Operator's Certification:
I certify that I have read this A ement and do>ereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name:./`' *0--�
Address: C/ t 0-1—
City: %3+/' State:
Zip:
Phone: rL—_. E-mail address:
Signature: Date: / " l
Permittee's Certification:
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: 11;10 k V
Signature: _ Date:
7r
FORM: LOA 06-16 Page 3 of 3

SOIL SURVEY
GRAPHIC SCALE
1 " = 660'
660, 0 660'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
N C-AL-15
Fields 1-3

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State of North Carolina
Department of Environmental Quality
D-W,- - .
Division of Water Resources
"-- COUNTY BOARD NOTIFICATION
Dtvlslon of Water Resources
INSTRUCTIONS FOR FORM: CBN 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 information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit
General -- This notification is intended to provide the county board in which the land application site is proposed to be located with
general information on the size, location and type of residuals land application proposed to occur in their county, and to give them an
opportunity to comment on the pending permitting request as stipulated in Session Law 2013-340. Notification is not required for
fields deemed permitted to receive Class A residuals under 15A NCAC 02T .1100. Do not submit this document for review
without a corresponding residuals program application form (FORM: RLAP 11-15).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. County Board Notification (FORM: CBN 11-15):
® Submit the completed and appropriately executed County Board Notification (FORM: CBN 11-15). Please do not make any
unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to the form may
be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
® Prepare a separate County Board Notification (FORM: CBN 11-15) for each county in which the proposed land application
sites are located.
B. Critical Watershed Areas Information:
® Under 15A NCAC 02B .0212, no new permitted sites for land application of residuals are allowed within critical watershed
areas. It is the Applicant's responsibility to ensure that the proposed land application sites are not located within these areas.
® For more information regarding Water Supply Watershed Protection Program, please visit the Division website at:
h s://de .nc. ov/abouttdivisions/water-resources/water-resources-rules/water-su 1 -watershed- rotection- ro am
❑ If uncertain about whether the proposed sites are located within the critical areas, contact the Division or call [phone].
C. Notification Package Submission:
❑ Complete and mail the notification letter, source facility summary, land application site summary, and site location maps to
the appropriate County Board by certified mail with a return receipt requested. It is recommended that a copy of the
notification package also be sent to the County Manager.
❑ The most current publication of the Directory of State and County _ Officials may be downloaded at:
hqs://www.sosnc.goy/Rublications/direct.aWx
❑ A list of the Division's regional offices, their county coverage, and their contact information may be downloaded at:
htM://deg.nc.gov/contact/regional-offices.
❑ The source facility summary shall include: facility name; county where it is located; and the proposed annual dry tonnage
(i.e., a copy of "Residuals Source Facility Summary" is adequate but not required).
❑ The land application site summary shall include: field ID; acreage; county where it is located; latitude and longitude (i.e., a
copy of "Land Application Site Certification" is adequate but not required).
D. Proof of Submission:
❑ Attach an 8.5 by I 1-inch copy of the return receipt to the back of this attachment prior to submission of the application to the
Division for review.
INSTRUCTIONS FOR FORM: CBN 06-16 Page I of I

North Carolina Department of Environmental Quality
Pat McCrory Donald R. van der Vaart
Governor Secretary
Date: 04/13/2020
Name of Chairman to the Board of County Commissioners: Ryan MaybgU
Complete mailing address: 621 Liledoun Rd
City: Ta. lode State: NC Zip: 28681
County where land application sites are located: Alexander
From: Applicant's name: Synagro Western Piedmont for Statesville Waste Water (on behalf of the Division of Water
Resources in accordance with Session Law 2013-340)
Contact person and title: Alex Fox
Complete mailing address: 284 Bo eg r rd
City: Statesville
Telephone number: (336) 703-$681
State: NC Zip: 27028 i
E-mail address: [e-mail]
Subject: Notification of residual land application site proposal
This is to notify you that the Applicant listed above will be submitting an application to the Division of Water
Resources for the land application of residual solids to site(s) located in your county. During this review, the Division
will ensure that all federal and state regulations are enforced. Attached to this form is information regarding residuals -
generating sources and locations of the proposed land application sites. Please forward this letter and its associated
attachments to the appropriate Departinent within your County (i.e., Health or Environmental Health Department and
Planning Department) if applicable.
More information of the land application sites included in this application will be available at the following
Division of Water Resources Regional Office:
Name of appropriate regional office: Mooresville Regional Office
Complete mailing address: 610 East Center Avenue Suite 301
City: Mooresville
State: NC
Telephone number: (704-235-2184)
Expected date of application submission: 04/15/2020
Zip: 28115
Should you desire to comment on this application, please do so no later than 30 calendar days following the
expected application submission date. If you have any questions or comments about this notification, or if you would like
more information, please contact the appropriate regional office at the telephone number provided above. Thank you in
advance for your attention to this matter.
Enclosures: Source Facility Summary
Land Application Site Summary
Maps
Non -Discharge Pennitting Unit
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Phone: 919-M47-64641Internet htto:1/aortal,ncdenr.om1we&wa
An Equal Opportunity 1 Affirmative Action Employer - Made in part with recycled paper
FORM: CBN 06-16

Alex Fox
From: UPS Quantum View <[e-mail]>
Sent: Tuesday, April 14, 2020 9:14 AM
To: Alex Fox
Subject: UPS Delivery Notification, Tracking Number 1Z51 F78W0101154909
Hello, your package has been delivered.
Scheduled Delivery Date: Tuesday, 04/14/2020
Estimated Delivery Time: End Of Day
Left At: INSIDE DELIV
Signed by: LINDA
SYNAGRO - MOCKSVILLE
INSIDE DELIV
Tracking Number: 1Z51F78WO101154909
Ship To: 621 LILEDOUN RD
TAYLORSVILLE; NC 28681
US
Number of Packages: 0
UPS Service: UPS Next Day Air@
Package Weight: 0.05 LBS
Reference Number: 20-2360-30-60-4310 50-0055
Q Download the UPS mobile aou
@ 2020 United Parcel Service of America, Inc. UPS, the UPS brandmark, and the color brown are
trademarks of Unified Parcel Service of America, Inc. All rights reserved.
All trademarks, trade names, or service marks that appear in connection with UPS's services are the
property of their respective owners.
1

Please do not reply directly to this email. UPS will not receive any reply message.
Review the UPS Pri►iacv Notice
For Questions, Visit Our Help and Support Center
M

State of North Carolina
Department of Environmental Quality
Division of Water Resources
l)lvlsion of Water Resources
15A NCAC 02T .1100 - 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 theApplicant shall submit one on inal and two copies of the application and
supportins documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit.
General - This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class 13 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):
�ubmit the completed and appropriately executed Land Application Site 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
fer.
Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
A licant.
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: � M �141 Lrn & � 1oy.A 7 -
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following Iand
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 -till over -seed/
pasture)
jJ
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 Iand 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

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: h
Address: /Z I _ L4 lG
City: ��.s..�% State: zip: Mi rr
Phone: r E-mail address: Tt, !� w
Signature: Date:
NORTH CAROLINA, +! X 4.4 401— _ _ _ COUNTY
I, the undersigned Notary Public do hereby certify that k-f✓ky. 44 �s
personally appeared before me this day and acknowledged the due execution of the forgoing instrument. X !�!i
WITNESS my hand and official seal this the 3 eo
day of QWN
ff // , 20.
Signature and seal: �+•
My cornmissioh expires: 00 t G _Zc _ Zq
Lessee's/Operator's Certification:
H
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: Zip:
E-mail address:
Date:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
^1
Signing official nar�pe:, 0 t' Q"� t� T�
Signature: Date: Y -6
FORM: LOA 06-16 Page 3 of 3

APPLICATION MAP
fL'
a
z
LEGEND
�a
APPLICATION AREA
PRIVATE ROAD
STREAM
DRAIN
X X X FENCE
I a 00 11:12 VA I ILI I il
UNSUITABLE AREA
WATER
ONSITE HOUSE GRAPHIC SCALE
.
OFFSITE HOUSE 1=660'
OUTBUILDING 660' 0 660'
(0
WELL
Q
SOIL BORING
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate,
NC-AL-16
Field 1

SOIL SURVEY
GRAPHIC SCALE
V=660'
68a' 0 660'
I � �
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within N C_AL-16
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate. Field 1

TOPOGRAPHIC MAP
GRAPHIC SCALE
1 " = 800'
800' 0 800,
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within N C-AL- 16
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate. Field 1

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State of North Carolina
Department of Environmental Quality
Division of Water Resources
W_R
"0
Dllvlsion of Water Resources
T . COUNTY BOARD NOTIFICATION
.
INSTRUCTIONS FOR FORM: CBN 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 information, visit the Water Quality Permitting ,Section's Non -Discharge Perwittft Unit
General -- This notification is intended to provide the county board in which the land application site is proposed to be located with
general information on the size, location and type of residuals land application proposed to occur in their county, and to give them an
opportunity to comment on the pending permitting request as stipulated in Session Law 2013-340. Notification is not required for
fields deemed permitted to receive Class A residuals under 15A NCAC 02T .1100. Do not submit this document for review
without a corresponding residuals program application form (FORM: RLAP 11-15).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. County Board Notification (FORM: CBN 11-15):
® Submit the completed and appropriately executed County Board Notification (FORM: CBN 11-15). Please do not make any
unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to the form may
be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
® Prepare a separate County Board Notification (FORM: CBN 11-15) for each county in which the proposed land application
sites are located.
B. Critical Watershed Areas Information:
® Under 15A NCAC 02B .0212, no new permitted sites for land application of residuals are allowed within critical watershed
areas. It is the Applicant's responsibility to ensure that the proposed land application sites are not located within these areas.
® For more information regarding Water Supply Watershed Protection Program, please visit the Division website at:
https://deu.nc. aov/about/divisions/water-resources/water-resources-rules/water-sunnty-watershed-protection-program
❑ If uncertain about whether the proposed sites are located within the critical areas, contact the Division or call [phone].
C. Notification Package Submission:
❑ Complete and mail the notification letter, source facility summary, land application site summary, and site location maps to
the appropriate County Board by certified mail with a return receipt requested. It is recommended that a copy of the
notification package also be sent to the County Manager.
❑ The most current publication of the Directory of State and County Officials may be downloaded at:
hM2s://www.sosnc.p-oy/publications/direct.amx
❑ A list of the Division's regional offices, their county coverage, and their contact information may be downloaded at:
hqp://deg.ne.gov/contact/regional-offices.
❑ The source facility summary shall include: facility name; county where it is located; and the proposed annual dry tonnage
(i.e., a copy of "Residuals Source Facility Summary" is adequate but not required).
❑ The land application site summary shall include: field ID; acreage; county where it is located; latitude and longitude (i.e., a
copy of "Land Application Site Certification" is adequate but not required).
D. Proof of Subm fission:
❑ Attach an 8.5 by 11-inch copy of the return receipt to the back of this attachment prior to submission of the application to the
Division for review.
INSTRUCTIONS FOR FORM: CBN 06-16 Page 1 of 1

North Carolina Department of Environmental Quality
Pat McCrory Donald R. van der Vaart
Governor Secretary
Date: 04/13/2020
Name of Chairman to the Board of County Commissioners: Ryan Marry
Complete mailing address: 621 Liledoun Rd
City: Taylorsyille State: NC Zip: 28681
County where land application sites are located: Alexander
From: AppIicant's name: Sy_nagro_ Western Piedmont for Statesville Waste Water (on behalf of the Division of Water
Resources in accordance with Session Law 2013-340)
Contact person and title: Alex Fox
Complete mailing address: 284 Boger rd
City: Statesville
Telephone number: [phone]
State: NC Zip: 27028
E-mail address: afox@a ynap-ro.com
Subject: Notification of residual land application site proposal
This is to notify you that the Applicant listed above will be submitting an application to the Division of Water
Resources for the land application of residual solids to site(s) located in your county. During this review, the Division
will ensure that all federal and state regulations are enforced. Attached to this forin is information regarding residuals -
generating sources and locations of the proposed land application sites. Please forward this letter and its associated
attachments to the appropriate Department within your County (i.e., Health or Environmental Health Department and
Planning Department) if applicable.
More infori-nation of the land application sites included in this application will be available at the following
Division of Water Resources Regional Office:
Name of appropriate regional office: MooresviIIe Regional Office
Complete mailing address: 610 East Center Avenue Suite 301
City: Mooresville
Telephone number: (704-235-2184)
State: NC Zip: 28115
Expected date of application submission: 04/15/2020
Should you desire to comment on this application, please do so no later than 30 calendar days following the
expected application submission date. If you have any questions or comments about this notification, or if you would like
more information, please contact the appropriate regional office at the telephone number provided above. Thank you in
advance for your attention to this matter.
Enclosures: Source Facility Summary
Land Application Site Summary
Maps
Non -Discharge permitting Unit
1617 Mail service Center, Raleigh, North Carolina 27699-1617
Phone: [phone] Intemet http:llcoM.ncdenr.am/weblwg
An Equal Opportunity 4 Affirmative Action Employer— Made in part with recycled paper
FORM: CBN 06-16

Alex Fox
From: UPS Quantum View <[e-mail]>
Sent: Tuesday, April 14, 2020 9:14 AM
To: Alex Fox
Subject: UPS Delivery Notification, Tracking Number 1Z51 F78W0101154909
Hello, your package has been delivered.
Scheduled Delivery Date: Tuesday, 04/14/2020
Estimated Delivery Time: End Of. Day
Left At: INSIDE DELIV
Signed by: LINDA
SYNAGRO - MOCKSVILLE
INSIDE DELIV
Tracking Number:
Ship To:
Number of Packages:
UPS Service:
Package Weight:
Reference Number:
Q Download the UPS mobile aoD
1Z51 F78W0101154909
621 LILEDOUN RD
TAYLORSVILLE, NC 28681
US
0
UPS Next Day Air®
0.05 LBS
20-2360-30-60-4310 50-0055
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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 Dlicant shall submit one on final and two copies of the application and
supportinga documentation
For more information, visit the Water Quality Permitting S'ection's Non -Discharge Permitting, Unit
General — This document is an agreement between the Applicant and Iand 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 .I100. 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):
&Je5ubmit 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.
N41repare a separate agreement for each set of Iand application sites that are owned or operated by an entity other than the
A plicant.
copy of the completed and appropriately executed agreement must be provided to the Iandowner and the iesseelop erator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landowner or his representative hereby permits:
AppIicant's name: v P,
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following Iand
application site(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Lease;Land Use or Special note
Site/Field IDIntended Use of Crops Residuals Source
{yes/no)ping Patterns (optional) (no-till/over-seed/
(� pasture)
1.1 ' Uo3 " Zi 3 4, o /crt tr
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittec 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 I 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 site(s) specified by this Agreement.
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 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 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,
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 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 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 pH 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
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 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 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 leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
I1. RESTRICTIONS:
L 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 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. 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 .0I07(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC 02T .0105 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 mark one of the following;
❑ A re -defined compliance boundary is needed for field(s) ID:
(Please include the rationale for the requested re -location of the compliance boundary and attach
cc pliance boundary to the application package)
7
A re -defined compliance boundary is not needed for this site,
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
a map showing the newly proposed
❑ The land application field(s) ID: is currently permitted under another
residuals land application program; Permit Number WQ: The land owner hereby acknowledge that by signing this
agreement, he/she is requesting that the field(s) be removed from the previously permitted residuals land application program and transferred
into the new program;
(Name of the new program)
FORM: LOA 06-16 Page 2 of 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 sitc(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 Perrnittee to land apply residuals to the land application sites) as specified
herein. _
Landowner name; jr0_7 f j CA NCB / 5 T a l n
Address: O
City: GC State:_Zip: 6
Phone: E-mail address: f",' b, t Al- A e _�_oi,.i
Signature: 2
t 1 Date: F r Z( 26
NORTH CAROLINA, COUNTY
I, the undersigned Notary Public do hereby certify that 0JUr
1�t '. ( Sktftd
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the �.� ��0,'tit �x f W
day of b 320
Signature and seal:..
i
My commission expires: ZZZ , b2lQ s
Lessee's/Operator's Certification:
f 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
I certify that I have read this Agreement and do hereby
Signing official name:
Signature:
Zip:
Date:
to abide by the stipulations and restrictions as specified herein.
Date:
. 44Ak,_-)
FORM: LOA 06-16 Page 3 of 3

APPLICATION MAP
o■
1�
LEGEND
APPLICATION AREA
PRIVATE ROAD
STREAM
DRAIN
X X X-- FENCE
PROPERTY LINE
0
0
UNSUITABLE AREA
WATER
ONSITE HOUSE
OFFSITE HOUSE
OUTBUILDING
WELL
SOIL BORING
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
GRAPHIC SCALE
1"=660'
660' 0 660'
NC-CD-03
Fields 2-3

SOIL SURVEY
GRAPHIC SCALE
V=660'
660' 0 660'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
NC-CD-03
Fields 2-3

APPLICATION MAP
LEGEND
APPLICATION AREA
PRIVATE ROAD
STREAM
I-1111R.Iff
X X X FENCE
PROPERTY LINE
UNSUITABLE AREA
WATER
ONSITE HOUSE
OFFSITE HOUSE
OUTBUILDING
WELL
SOIL BORING
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
GRAPHIC SCALE
III =660'
660' 0 660'
NC-CD-03
Fields 6-7

SOIL SURVEY
GRAPHIC SCALE
1"=660'
660' 0 660'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
NC-CD-03
Fields 6-7

APPLICATION MAP
(C
LEGEND
PT7a
APPLICATION AREA
PRIVATE ROAD
STREAM
110,11121
FENCE
PROPERTY LINE
UNSUITABLE AREA
WATER
ONSITE HOUSE
OFFSITE HOUSE GRAPHIC SCALE
=
1" 660'
OUTBUILDING
ssao sso
0
WELL
0
SOIL BORING
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
NC^CD=03
Field 9

SOIL SURVEY
GRAPHIC SCALE
III =660'
660' 0 660,
I. a
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
NC-CD-93
Fields 9

TOPOGRAPHIC MAP
GRAPHIC SCALE
V=1,000'
1 ppp' 0 1,OOp'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
NC-CD-03
Fields 2-3, 10

TOPOGRAPHIC MAP
VU
SPY' • Y F , �
� r��� �1��k \ � P. $D,�.
�� `�p�F,'��,LLiiq t r� Ti
��• �
r
�
� ` -•
11
-r•�,h'� + � �; ��
"
• a a Y
�
�i. "a
� i
W.
•
1
"
.t
9�
GRAPHIC SCALE
1 " = 800'
800, a soa,
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
NC-CD-03
Field 9

VICINITY MAP
GRAPHIC SCALE
1" = 4,000'
4,000` 6 4,000'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
NC-CD-03
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State of North Carolina
Department of Environmental Quality
Division of Water Resources
Divlslon of Water Resources COUNTY BOARD NOTIFICATION
INSTRUCTIONS FOR FORM: CBN 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 information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit
General —This notification is intended to provide the county board in which the land application site is proposed to be located with
general information on the size, location and type of residuals land application proposed to occur in their county, and to give them an
opportunity to comment on the pending permitting request as stipulated in Session Law 2013-340. Notification is not required for
fields deemed permitted to receive Class A residuals under 15A NCAC 02T .1100. Do not submit this document for review
without a corresponding residuals program application form (FORM: RLAP 11-15).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. County Board Notification (FORM: CBN 11-15):
® Submit the completed and appropriately executed County Board Notification (FORM: CBN 11-15). Please do not make any
unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to the form may
be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
® Prepare a separate County Board Notification (FORM: CBN 11-15) for each county in which the proposed land application
sites are located.
13. Critical Watershed Areas Information:
® Under 15A NCAC 02B .0212, no new permitted sites for land application of residuals are allowed within critical watershed
areas. It is the Applicant's responsibility to ensure that the proposed land application sites are not located within these areas.
® For more information regarding Water Supply Watershed Protection Program, please visit the Division website at:
h s://deg.nc.gov/about/divisions/water-resources/water-resources-rules/water-supply-watershed-protection-program
❑ If uncertain about whether the proposed sites are located within the critical areas, contact the Division or call [phone].
C. Notification Package Submission:
❑ Complete and mail the notification letter, source facility summary, land application site summary, and site location maps to
the appropriate County Board by certified mail with a return receipt requested. It is recommended that a copy of the
notification package also be sent to the County Manager.
❑ The most current publication of the Directory of State and County Officials may be downloaded at:
hops://www.sosne.goy/publications/direct.aspx
❑ A list of the Division's regional offices, their county coverage, and their contact information may be downloaded at:
http://deq.nc.gov/contact/regional-offices.
❑ The source facility summary shall include: facility name; county where it is located; and the proposed annual dry tonnage
(i.e., a copy of "Residuals Source Facility Summary" is adequate but not required).
❑ The land application site summary shall include: field ID; acreage; county where it is located; latitude and longitude (i,e., a
copy of "Land Application Site Certification" is adequate but not required).
D. Proof of Submission:
❑ Attach an 8.5 by I I -inch copy of the return receipt to the back of this attachment prior to submission of the application to the
Division for review.
INSTRUCTIONS FOR FORM: CBN 06-16 Page 1 of I

North Carolina Department of Environmental Quality
Pat McCrory Donald R. van der Vaart
Governor Secretary
Date: 04/ 13 /2020
Name of Chairman to the Board of County Commissioners: Randy Church
Complete mailing address: 905 West Ave NW
City: Lenior State: NC Zip: 28645
County where land application sites are located: Caldwell
From: Applicant's name: S na ro Western Piedmont for Granite Falls Waste Water (on behalf of the Division of Water
Resources in accordance with Session Law 2013-340)
Contact person and title: Alex Fox
Complete mailing address: 284 Boger rd
City: Statesville
Telephone number: [phone]
State: NC Zip: 27028-Ia
E-mail address: [e-mail]
Subject: Notification of residual land application site proposal
This is to notify you that the Applicant listed above will be submitting an application to the Division of Water
Resources for the land application of residual solids to site(s) located in your county. During this review, the Division
will ensure that all federal and state regulations are enforced. Attached to this form is information regarding residuals -
generating sources and locations of the proposed land application sites. Please forward this letter and its associated
attachments to the appropriate Department within your County (i.e., Health or Environmental Health Department and
Planning Department) if applicable.
More information of the land application sites included in this application will be available at the following
Division of Water Resources Regional Office:
Name of appropriate regional office: Asheville Regional Office
Complete mailing address: 2090 US-70
City: Swannanoa State: NC Zip: 28778
Telephone number: (828)-296-4500
Expected date of application submission: 04/15/2020
Should you desire to comment on this application, please do so no later than 30 calendar days following the
expected application submission date, if you have any questions or comments about this notification, or if you would like
more information, please contact the appropriate regional office at the telephone number provided above. Thank you in
advance for your attention to this matter.
Enclosures: Source Facility ,Summary
Land Application Site Summary
Maps
Non -Discharge Permitting Unit
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Phone: [phone]Internet: httpaloortal.ncdenr.oralweblwa
An Equal Opportunity 1 Aftirmalive Action Employer— Made in part with recycled paper FORM: CBN 06-16

Alex Fox
From: UPS Quantum View <[e-mail]>
Sent: Tuesday, April 14, 2020 9:48 AM
To: Alex Fox
Subject: UPS Delivery Notification, Tracking Number 1Z51F78W0197016058
Hello, your package has been delivered.
Scheduled Delivery Date: Tuesday, 04/14/2020
Estimated Delivery Time: End Of Day
Left. At. RECEIVER.
Signed by: WHITT
SYNAGRO MOCKSVILLE
RECEIVER
Tracking Number: 1Z51F78W0197016058
Ship To: 905 WEST AVE NW
LENOIR, NC 28645
us
Number of Packages: 0
UPS Service: UPS Next Day Aire
Package Weight: 0.05 LBS
Reference Number: 20-2360-30-60-4310 50-0055
0
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State of North Carolina
DWR
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 information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit
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 A 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. 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.
® Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
® 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#J~0%
ermits:
Applicant's name: _S� n&e ro W.[S� Ltn
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the fallowing 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
es/no
(3 )
Land Use or
Cropping Patterns
pp' $
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
3 ( - 3 5
AAlpt.r
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 I of 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: j� y i�, 6y+'n -e/—
Address:
City: t�� Stater Zip::
Phone: 70-F - (0 1 SAS E-mail address: ! 0 C.97rn C . 1-�_Q�
Signature: Date d_Ca C
NORTH CAROLINA, _J:/� AC t J COUNTY j
I, the undersigned Notary Public do hereby certify that �1f S C,c inr
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the ,��x' w
{ � i
day of c rC, , 20
Signature and seal: 2 r" 0
My commission expires: Z r �J i 4
�4._ C r_nt�N _.��♦
Lessee's/Operator's Certification:
NI
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified here in.
Lesseeloperator 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:
Signature: �� Date:
FORM: LOA 06-16 Page 3 of 3

Im State of North Carolina
El MF Dw K 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 co ies of the application and
sunnortine documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit
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
male 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
Applicant.
® 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:
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)
�w. r � G
Xv
Ito, 40VA9
Ar
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

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: 6J
Address: 9
City: State: 62C - _ Zip: Y✓ c
1
Phone: E-mail address: k n IS jL C, to e�
Signature: f t/., / _ Date: 'N A' '-
NORTH CAROLINA, �L, e l 1 _ COUNTY ii
I, the undersigned Notary Public do hereby certify that U l t . _
personally appeared before me this day and acknowledged the due execution of the forgoing instrument. ,�Nllfill
.-L 1X
WITNESS my hand and official seal this the .213
� , W
day of r, rr, 20 23
Signature and seal: t
r
My commission expires:
if. _4 /1wa vw
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:
I certify that I have read this
Signing official name:
Signature:
State:
E-mail address:
Date:
Zip:
and do hereby agree to abide by the stipulations and restrictions as specified herein.
Date:
FORM: LOA 06-16 Page 3 of 3

APPLICATION MAP
a
z
a
LEGEND
APPLICATION AREA F/�]
PRIVATE ROAD
STREAM
DRAIN
X X X FENCE
PROPERTY LINE
0
G)
UNSUITABLE AREA
WATER
ONSITE HOUSE
OFFSITE HOUSE
OUTBUILDING
WELL
SOIL BORING
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
GRAPHIC SCALE
1 " = 660'
660' 0 660,
N C-I R-36
Fields 1-2

APPLICATION MAP
LEGEND
APPLICATION AREA V
PRIVATE ROAD
STREAM
DRAIN
X X X FENCE
PROPERTY LINE
0
0
UNSUITABLE AREA
WATER
ONSITE HOUSE
OFFSITE HOUSE
OUTBUILDING
WELL
SOIL BORING
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
GRAPHIC SCALE
1 " = 660'
660' 0 660,
NC-IR-36
Fields 3-4

APPLICATION MAP
LEGEND
APPLICATION AREA
PRIVATE ROAD
STREAM
DRAIN
X X X FENCE
PROPERTY LINE
El
0
0
LP►63IIFF.11.3A412 V.
WATER
Frk61"aso[am 61A
OFFSITE HOUSE
OUTBUILDING
WELL
SOIL BORING
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
GRAPHIC SCALE
1 " = 660'
sso' 0 sse'
N C- I R-36
Field 5

SOIL SURVEY
GRAPHIC SCALE
1" = 660'
660' a ssa'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
Fields 3-4

TOPOGRAPHIC MAP
GRAPHIC SCALE
1 ° = 800'
800, 0 600,
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
N C-I R-36
Fields 1-2

6
TOPOGRAPHIC MAP
0 0
a1
GRAPHIC SCALE
1 1,000'
1,000' 0 1,000'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
N C- I R-36
Fields 3-5

VICINITY MAP
GRAPHIC SCALE
1 ° = 4,000'
4,OOD' p 4,000'
I r.rri rrr � J
The compliance boundary is established either 250 ftfrom the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
01[4a1\61•
locations are approximate.
Fields 1-5

State of North Carolina
Department of Environmental Quality
WR Division of Water Resources
zs.... COUNTY BOARD NOTIFICATION
`" Dlylslnn, of Water Resources
INSTRUCTIONS FOR FORM: CBN 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
su or_t_ing documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit
General — This notification is intended to provide the county board in which the land application site is proposed to be located with
general information on the size, location and type of residuals land application proposed to occur in their county, and to give them an
opportunity to comment on the pending permitting request as stipulated in Session Law 2013-340. Notification is not required for
fields deemed permitted to receive Class A residuals under 15A NCAC 02T .1100. Do not submit this document for review
without a corresponding residuals program application form (FORM: RLAP 11-15).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. County Board Notification (FORM: CBN 11-15):
® Submit the completed and appropriately executed County Board Notification (FORM: CBN 11-15). Please do not make any
unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to the form may
be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
® Prepare a separate County Board Notification (FORM: CBN 11-15) for each county in which the proposed land application
sites are located.
B. Critical Watershed Areas Information:
® Under 15A NCAC 02B .0212, no new permitted sites for land application of residuals are allowed within critical watershed
areas. It is the Applicant's responsibility to ensure that the proposed land application sites are not located within these areas.
® For more information regarding Water Supply Watershed Protection Program, please visit the Division website at:
b.Aps://deg.nc.aov/about/divisions/water-resources/water-resources-rules/water-sLioly-watershed-protection-progLam
❑ If uncertain about whether the proposed sites are located within the critical areas, contact the Division or call [phone].
C. Notification Package Submission:
F!Lol' Complete and mail the notification letter, source facility summary, land application site summary, and site location maps to
the appropriate County Board by certified mail with a return receipt requested. It is recommended that a copy of the
notification package also be sent to the County Manager.
the most current publication of the Directory of State and County Officials may be downloaded at:
httj)s://www.sosnc.gov/publications/direct.aVx
A list of the Division's regional offices, their county coverage, and their contact information may be downloaded at:
httn://deg.nc.gov/contact/regional-offices.
e source facility summary shall include: facility name; county where it is located; and the proposed annual dry tonnage
(i.e., a copy of "Residuals Source Facility Summary" is adequate but not required).
E4-1'h�e land application site summary shall include: field ID; acreage; county where it is located; latitude and Iongitude (i.e., a
` copy of "Land Application Site Certification" is adequate but not required).
D. Proof of Submission:
❑ Attach an 8.5 by 11-inch copy of the return receipt to the back of this attachment prior to submission of the application to the
Division for review.
INSTRUCTIONS FOR FORM: CBN 06-16 Page 1 of 1

North Carolina Department of Environmental Quality
Pat McCrory Donald R. van der Vaart
Governor Secretary
Date: 10/2/19
Name of Chairman to the Board of County Commissioners: James Mallory
Complete mailing address: 519 N Centter Street
City: Statesville State: NC Zip: 28677
County where land application sites are located: Iredell
From.: Applicant`s name: Synagro Western Piedmont for Statesville Waste Water (on behalf of the Division of Water
Resources in accordance with Session Law 2013-340)
Contact person and title: Alex Fox
Complete mailing address: 284 Boger rd
City: Statesville
Telephone number: [phone]
State: NC Zip: 27028 � t
E-mail address: [e-mail]
Subject: Notification of residual land application site proposal
This is to notify you that the Applicant listed above will be submitting an application to the Division of Water
Resources for the land application of residual solids to site(s) located in your county. During this review, the Division
will ensure that all federal and state regulations are enforced. Attached to this form is information regarding residuals -
generating sources and locations of the proposed land application sites. Please forward this letter and its associated
attachments to the appropriate Department within your County (i.e., Health or Environmental Health Department and
Planning Department) if applicable.
More information of the land application sites included in this application will be available at the following
Division of Water Resources Regional Office:
Name of appropriate regional office: Mooresville Regional Office
Complete mailing address: 610 East Center Avenue Suite 3 01
City: Mooresville State: NC Zip: 28115
Telephone number: (704-235-2184)
Expected date of application submission: 04/15/2020
Should you desire to comment on this application, please do so no later than 30 calendar days following the
expected application submission date. If you have any questions or comments about this notification, or if you would like
more information, please contact the appropriate regional office at the telephone number provided above. Thank you in
advance for your attention to this matter.
Enclosures: Source Facility Summary
Land Application Site Summary
Maps
Non -Discharge Permitting Unit
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Phone: 91 M07-6464 1 Internet: htto:/Ioortal.ncdenr.org/wehhvg
An Equal Opportunity 4Affirmative Action Employer- Made in part with recycled paper FORM: CBN 06-16

Alex Fox
From: UPS Quantum View <[e-mail]>
Sent: Tuesday, April 14, 2020 9:08 AM
To: Alex Fox
Subject: UPS Delivery Notification, Tracking Number 1z51 F78W0197388031
Hello, your package has been delivered.
Scheduled Delivery Date: Tuesday, 04/14/2020
Estimated. Delivery Time: End Of Day
Left At: FRONT DOOR
Set Delivery Instructions
Manage Preferences View Delivery Planner
SYNAGRO - MOCKSVIrLLE
FRONT DOOR
Tracking Number:
1Z51F78W0197388031
Ship To.-519
N CENTER ST
STATESVILLE, NC 28677
us
Number of Packages:
0
UPS Service:
UPS Next Day Air@
Package Weight:
0.05 LBS
Reference Number;
20-2360-30-60-4310 50-0055
1

Download the UPS mobile ap❑
© 2020 United Parcel Service of America, Inc. UPS, the UPS brandmark, and the color brown are
trademarks of United Parcel Service of America, Inc. All rights reserved.
All trademarks, trade names, or service marks that appear in connection with UPS's services are the
property of their respective owners.
Please do not reply directly to this email. UPS will not receive any reply message.
Review the UPS Privacy Notice
For Questions, Visit Our Help and Support Center

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Dlvislon of Water Resources
15A NCAC 02T .1100 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 Iead 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 information, visit the Water Quality Permitting Section's Non-Dlschar?,e Permjtdgg Unit.
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 carresponding 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. Lan Owner Agreement (FORM: LOA 06-16):
Submit the completed and appropriately executed Land Application Site Certification (NORM: LASC 06-16) form. PIease
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.
V11"p,repare a separate agreement for each set of Iand application sites that are owned or operated by an entity other than the
plicant.
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: Sy�lw c /O 1 �I�s "'ran J� a MMco I
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-till/over-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 Page 1 of 3

Landowner's Certification:
I certify that I am a deeded Iandowner 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. % I
Landowner name: �[` 1�� L a
Address: ! 7 a `i� AG �rQ
City: C f e b,( LA �i -- -- State: ! °' Zip:. 7 r ,-
Phone: Q' 7 (� ( �! l E-mail address:
Signature: �"� �{- '`" Date:
NORTH CAROLINA, & � A- COUNTY
1, the undersigned Notary Public do hereby certify that �A1 Y� A,���✓t
personally appeared before me this day and acknowledged thedueexecution of the forgoing instrument.
WITNESS my hand d official seal this the Z l7Ih iF
day of , 20 1 '�
y
Signature and seal:
``^^ : P11
My commission expires: V 2 7 CKIV
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 nam ad��-
Signature: '! Date: 9 f�
FORM: LOA 06-16 Page 3 of 3

APPLICATION MAP
LEGEND
APPLICATION AREA
UNSUITABLE AREA
— — — -- --
PRIVATE ROAD
WATER
GRAPHIC SCALE
--- — — —
STREAM
.
ONSITE HOUSE 1 - 660'
—
DRAIN
660' a 660,
.
OFFSITE HOUSE
FENCE
OUTBUILDING
PROPERTY LINE
WELL
Q
SOIL BORING
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within N C-RA-05
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate. Fields 1-2

APPLICATION MAP
LEGEND
APPLICATION AREA
UNSUITABLE AREA
— — — — — — PRIVATE ROAD
WATER
— — — STREAM
.
ONSITE HOUSE
— DRAIN
OFFSITE HOUSE
)XFENCE
OUTBUILDING
PROPERTY LINE
0 SOIL BORING 0 WELL
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
GRAPHIC SCALE
1 " = 660'
sso' 0 sso'
N C-RA-05
Fields 2-3

SOIL SURVEY
GRAPHIC SCALE
1" = 800'
800, a &Oa,
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within N C-RA-05
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate. Fields 1-3

VICINITY MAP
Ln
L--
� -�
-.. ;L . �\ `�'L/{ I , f �\ • '11 '. l I J i -
` �•_awf� f � \
ti- i
\
/ i` -�
/
�-/r� I \ "( P ,/` Jel 'P �/ i \:°S \�` / k f I `�\ ✓ 5'_
F�_,'
F L
'/ f 1, 1.( r
,✓ I 1 \2
`�A �
I / f Yl ` •! y _
f I 1 e �1 ` ` -
� . ��F�
i ce, , \ %. t e2
r I }� % 3 i^ till { ^�_� 4 '` _�},` .. ...L_ J 'iQ ✓
\ `` i �� _
'� � � � �l�`-��l 4-�- �` _ F ��e � � � I� I >✓9: t! 1 i
� I �L �
, %t F -�
� � � ��
( , 11
�
T
V�
CR
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GRAPHIC SCALE
1" = 4,000'
4,000' 0 4,000`
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
N C^RA-05
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
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- Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
COUNTY BOARD NOTIFICATION
INSTRUCTIONS FOR FORM: CBN 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 A licant shall submit one original and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non-Dischar e Permitting Unit
General — This notification is intended to provide the county board in which the land application site is proposed to be located with
general information on the size, location and type of residuals land application proposed to occur in their county, and to give them an
opportunity to comment on the pending permitting request as stipulated in Session Law 2013-340. Notification is not required for
fields deemed permitted to receive Class A residuals under 15A NCAC 02T .1100. Do not submit this document for review
without a corresponding residuals program application form (FORM: RLAP 11-15).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. County Board Notification (FORM: CBN 11-15):
® Submit the completed and appropriately executed County Board Notification (FORM: CBN 11-15). Please do not make any
unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to the form may
be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
® Prepare a separate County Board Notification (FORM: CBN 11-15) for each county in which the proposed land application
sites are located.
B. Critical Watershed Areas Information:
® Under 15A NCAC 02B .0212, no new permitted sites for land application of residuals are allowed within critical watershed
areas. It is the Applicant's responsibility to ensure that the proposed land application sites are not located within these areas.
® For more information regarding Water Supply Watershed Protection Program, please visit the Division website at:
h s://de .nc. ov/about/divisions/water-resources/water-resources-rules/water-su 1 -watershed- rotection- ro am
❑ If uncertain about whether the proposed sites are located within the critical areas, contact the Division or call [phone].
C. Notification Package Submission:
❑ Complete and mail the notification letter, source facility summary, land application site summary, and site location maps to
the appropriate County Board by certified mail with a return receipt requested. It is recommended that a copy of the
notification package also be sent to the County Manager.
❑ The most current publication of the Directo1y of State and Coun Officials may be downloaded at:
hMs://www.sosrie.gov/publications/direct.asvx
❑ A list of the Division's regional offices, their county coverage, and their contact information may be downloaded at:
bM2.//deg.nc.gov/contact/regional-offices.
❑ The source facility summary shall include: facility name; county where it is located; and the proposed annual dry tonnage
(i.e., a copy of "Residuals Source Facility Summary" is adequate but not required).
❑ The land application site summary shall include: field ID; acreage; county where it is located; latitude and longitude (i.e., a
copy of "Land Application Site Certification" is adequate but not required).
D. Proof of Submission:
❑ Attach an 8.5 by 11-inch copy of the return receipt to the back of this attachment prior to submission of the application to the
Division for review.
INSTRUCTIONS FOR FORM: CBN 06-16 Page 1 of 1

North Carolina Department of Environmental Quality
Pak McCrory Donald R. van der Vaart
Governor Secretary
Date: 04/13/2020
Name of Chairman to the Board of County Commissioners: Greg Edds
Complete mailing address: 130 W Innes Street
City: Salisbury State: NC Zip: 28144
County where land application sites are located: Rowan
From: Applicant's name: S na ro Western Piedmont for Statesville Waste Water (on behalf of the Division of Water
Resources in accordance with Session Law 2013-340)
Contact person and title: Alex Fox
Complete mailing address: 284 Boger Rd
City: Statesville State: NC Zip: 27028-,.
Telephone number: [phone] E-mail address: afox o synagro.com
Subject: Notification of residual land application site proposal
This is to notify you that the Applicant listed above will be submitting an application to the Division of Water
Resources for the land application of residual solids to site(s) located in your county. During this review, the Division
will ensure that all federal and state regulations are enforced. Attached to this form is information regarding residuals -
generating sources and locations of the proposed land application sites. Please forward this letter and its associated
attachments to the appropriate Department within your County (i.e., Health or Environmental Health Department and
Planning Department) if applicable.
More information of the land application sites included in this application will be available at the following
Division of Water Resources Regional Office:
Name of appropriate regional office: Mooresville Regional Office
Complete mailing address: 610 East Center Avenue Suite 301
City: Mooresville State: NC Zip: 28115
Telephone number: (704-235-2184)
Expected date of application submission: 04/15/2020
Should you desire to comment on this application, please do so no later than 30 calendar days following the
expected application submission date. If you have any questions or comments about this notification, or if you would like
more information, please contact the appropriate regional office at the telephone number provided above. Thank you in
advance for your attention to this matter.
Enclosures: Source Facility Summary
Land Application Site Summary
Maps
Non -Discharge Permitting Unit
1617 Mail Service Center, Raleigh, North Carolina 27699-1617
Phone: 91 M07-6464 1 Internet: http://portal.ncdenr.orgfwebfwg
An Equal Opportunity\ Affirmative Action Employer —Made in partwith recycled paper FORM: CBN 06-16

Alex Fox
From: UPS Quantum View <[e-mail]>
Sent: Tuesday, April 14, 2020 9:52 AM
To: Alex Fox
Subject: UPS Delivery Notification, Tracking Number 1Z51F78W0197302248
Hello, your package has been delivered.
Scheduled Delivery Date:. Tuesday, 04/14/2020
Estimated Delivery Time: End Of Day
Left At: FRONT DESK
.Signed by: GOODMAN
SYNAGRO - MOCKSVILLE
FRONT DESK
Tracking Number:
1ZSiF78WO197302248
Ship To:
130 W INNES ST
SALISBURY, NC 28144
US
Number of.Packages:
0
UPS Service:
UPS Next bay Air@
Package Weight:
0.05 LBS
Reference Number: ...
20-2360-30-60-4310 50-0055
I Ixl I Download the UPS mobile anD
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M

State of North Carolina
DWR Department of Environment and Natural Resources
Division of Water Resources
Dlvislon 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 information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit
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):
ubmit 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.
�repare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
A plicant.
copy of the completed and appropriately executed agreement must be provided to the landowner and the Iessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
The undersigned landown r or his representative hereby permits: /
Applicant's name: ,P /` / `e, Le-,"
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
o tional
(p
Special note
(no-till/over-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 Page I of 3

L STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the site(s) specified by this Agreement.
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 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 NCDENR-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 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 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.
S. 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 pH of the soil, residuals and time 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
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 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 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 leachate, surface water, groundwater, or soil 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 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. Turf grown on land where residuals are applied shall not be harvested for a 12-month period following a residuals land application event.
IILALTERNATIVES 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 .0105(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. PIease mark one of the following;
❑ A re -defined compliance boundary is needed for field(s) ID:
(Please include the rationale for the requested re -location of the compliance boundary and attach a map showing the newly proposed
mpliance boundary to the application package)
EE(A re -defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
❑ The land application field(s) ID: is currently permitted under another
residuals land application program; Permit Number WQ: The land owner hereby acknowledge that by signing this
agreement, he/she is requesting that the fields) be removed from the previously permitted residuals land application program and transferred
into the new program;
(Name of the new program)
FORM: LOA 06-16 Page 2 of 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 sites) 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:
Address: (P ,
City: i Fv✓ State: _ Gt Zip:
Phone: 77 o Y- e a 6 E-mail address: Signature: Date: -1 U
9
NORTH CAROLINA, �O W CD TY
! O,I the undersigned Notary JPublic do hereby certify that `
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
I�
WITNESS my hand and official seal this the
day of
Signature and seal:
My commission expires:
Lessee's/Operator's Certification:
Z
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
Date:
Zip:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Sigiung official n e: rI ok-e r
Signature: Date:
FORM: LOA 06-16 Page 3 of 3

State of North Carolina
DW
Department of Environment and Natural Resources
Division of Water Resources
DtYlslon 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 orilzinal and two copies of the a lication and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit
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
ff Pplication may be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
repare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
_,Applicant.
AA 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: slam, asjZ 10+r+l
hereinafter referred to as the Permittee, to Iand 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 Ill
Lease
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
o tional
(p
Special note
(no-till/over-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 site(s) specified by this Agreement.
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 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 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.
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 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 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 pH 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
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 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 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 leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
H. 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 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. 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 .0105 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 mark one of the following;
❑ A re -defined compliance boundary is needed for field(s) ID:
(Please include the rationale for the requested re -location of the
compliance boundary to the application package)
[eA re -defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
compliance boundary and attach a map showing the newly proposed
❑ The land application field(s) ID: is currently permitted under another
residuals land application program; Permit Number WQ: The land owner hereby acknowledge that by signing this
agreement, he/she is requesting that the field(s) be removed from the previously permitted residuals land application program and transferred
into the new program;
{Name of the new program} ,
FORM: LOA 06-16 Page 2 of 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 applications site(s) on behalf of other deeded landowners OR that I anti 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 sites) 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: It —do
Address:
' . 6. Zip: A g �
City: � D��-7 / State: _ j
Phone: —) d a ` G L rO E-mail address:
Signature: r'�`� Date:
`'"�1!
NORTH CAROLINA, y✓ COUNTY T'
I, the undersigned Notary Public do hereby certify that P i I. _,�./'"�� �3-
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the
day of 'Jt(seCA►� l ,20
Signature and seal:
C?
My commission expires:to
Lessee's/Operator's Certification: �//%111CO1���,�
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessec/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:
Signature:
Date: `r �� &� -
T
FORM: LOA 06-16 Page 3 of 3

M
APPLICATION MAP
LEGEND
PT7a
APPLICATION AREA
PRIVATE ROAD
STREAM
DRAIN
— FENCE
PROPERTY LINE
UNSUITABLE AREA
CD
WATER
ONSITE HOUSE GRAPHIC SCALE
1"=660'
OFFSITE HOUSE
OUTBUILDING s6ti 6 660'
,.terms �w i
(�
WELL
0
SOIL BORING
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate.
N C-RA-53
Fields 1-2

SOIL SURVEY
a
z(n
GRAPHIC SCALE
1 " = 660'
660' 0 660'
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within N C-RA-53
in the property boundary, whichever is closest to the application area. The review boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are approximate. Fields 1-2

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ID 7,
-,WR
Dlvlslon of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
COUNTY BOARD NOTIFICATION
INSTRUCTIONS FOR FORM: CBN 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 information, visit the Water Quality Permitting Section's Non-Discha)Ze Permitting_Unit
General — This notification is intended to provide the county board in which the land application site is proposed to be located with
general information on the size, location and type of residuals land application proposed to occur in their county, and to give them an
opportunity to comment on the pending permitting request as stipulated in Session Law 2013-340. Notification is not required for
fields deemed permitted to receive Class A residuals under 15A NCAC 02T .1100. Do not submit this document for review
without a corresponding residuals program application form (FORM: RLAP 11-15).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. County Board Notification (FORM: CBN 11-15):
® Submit the completed and appropriately executed County Board Notification (FORM: CBN I 1-15). Please do not make any
unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to the form may
be made, as long as the attachments are numbered to correspond to the section and item to which they refer.
® Prepare a separate County Board Notification (FORM: CBN 11-15) for each county in which the proposed land application
sites are located.
B. Critical Watershed Areas Information:
® Under 15A NCAC 02B .0212, no new permitted sites for land application of residuals are allowed within critical watershed
areas. It is the Applicant's responsibility to ensure that the proposed land application sites are not located within these areas.
® For more information regarding Water Supply Watershed Protection Program, please visit the Division website at:
hM2s://deq.nc.gov/about/divisions/water-resources/water-resources-rules/water-sgpl2ly-watershed:�protection-program
❑ If uncertain about whether the proposed sites are located within the critical areas, contact the Division or call [phone].
C. Notification Package Submission:
❑ Complete and mail the notification letter, source facility summary, land application site summary, and site location maps to
the appropriate County Board by certified mail with a return receipt requested. It is recommended that a copy of the
notification package also be sent to the County Manager.
❑ The most current publication of the DirectoEy of State and Co" Officials may be downloaded at:
hMs://www.sosnc.goy/Rublications/direct.asax
❑ A list of the Division's regional offices, their county coverage, and their contact information may be downloaded at:
hap://deg.nc.gov/contact/regional-offices.
❑ The source facility summary shall include: facility name; county where it is located; and the proposed annual dry tonnage
(i.e., a copy of "Residuals Source Facility Summary" is adequate but not required).
❑ The land application site summary shall include: field ID; acreage; county where it is located; latitude and longitude (i.e., a
copy of "Land Application Site Certification" is adequate but not required).
D. Proof of Submission:
❑ Attach an 8.5 by I I -inch copy of the return receipt to the back of this attachment prior to submission of the application to the
DIvision for review.
INSTRUCTIONS FOR FORM: CBN 06-16 Page 1 of 1

North Carolina Department of Environmental Quality
Pat McCrory Donald R. van der Vaart
Governor Secretary
Date: 04/13/2020
Name of Chairman to the Board of County Commissioners: Greg Edds
Complete mailing address: 130 W Inns Street
City: Salisbury State: NC Zip: 28144
County where land application sites are located: Rowan
From: Applicant's name: S na ro Western Piedmont for Statesville Waste Water (on behalf of the Division of Water
Resources in accordance with Session Law 2013-340)
Contact person and title: Alex Fox
Complete mailing address: 284 Bo eg r Rd
City: Statesville State: NC Zip: 2702$ i z
Telephone number: [phone] E-mail address: afo2j@syna rg o.com
Subject: Notification of residual land application site proposal
This is to notify you that the Applicant listed above will be submitting an application to the Division of Water
Resources for the land application of residual solids to site(s) located in your county. During this review, the Division
will ensure that all federal and state regulations are enforced. Attached to this form is information regarding residuals -
generating sources and locations of the proposed land application sites. Please forward this letter and its associated
attachments to the appropriate Department within your County (i.e., Health or Environmental Health Department and
Planning Department) if applicable.
More information of the land application sites included in this application will be available at the following
Division of Water Resources Regional Office:
Name of appropriate regional office: Mooresville Regional Office
Complete mailing address: 610 East Center Avenue Suite 301
City: Mooresville State: NC Zip: 28115
Telephone number: (704-235-2184)
Expected date of application submission: 04/15/2020
Should you desire to comment on this application, please do so no later than 30 calendar days following the
expected application submission date. If you have any questions or comments about this notification, or if you would like
more information, please contact the appropriate regional office at the telephone number provided above. Thank you in
advance for your attention to this matter.
Enclosures: Source Facility Summary
Land Application Site Summary
Maps
Non -Discharge Permitting Unit
1617 Mail Service Center, Raleigh, North Carolina 27699•1617
Phone: [phone]LInternet htt:l! ortal.ncdenr.o /weblw
An Equal opportunity 1 Affirmative Action Employer- Made in pad with recycled paper FORM: CBN 06-16

Alex Fox
From: UPS Quantum View <[e-mail]>
Sent: Tuesday, April 14, 2020 9:52 AM
To: Alex Fox
Subject: UPS Delivery Notification, Tracking Number IZ51F78W0197302248
Hello, your package has been delivered.
Scheduled Delivery Date: Tuesday, 04/14/2020
Estimated Delivery Time: End Of Day
Left At: FRONT DESK
Signed by: GOODMAN
SYNAGRO - MOCKSVILLE
FRONT DESK
Tracking Number:
Ship To:
Number of Packages:
UPS Service:
Package Weight:
Reference Number:
Q Download the UPS mobile aDD
1Z51F78WD197302248
130 W INNES ST
SALISBURY, NC 28144
US
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20-2360-30-60-4310 50-0055
101
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