WQ0001271_Application_20191126

November 18, 2019
N.C. Department of Environment and Natural Resources
Division of Water Resources
Water Quality Permitting Section — Non -Discharge Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617
ATTENTION: Mr. Nathaniel Thornburg
REFERENCE: APPLICATION FOR RENEWAL OF PERMIT # WQ0001271
CFPUA RLAP
Dear Mr. Thornburg:
On behalf of the Cape Fear Public Utilities Authority, Synagro is submitting this application
to renew the above referenced residuals land application permit. Changes to the current permit
are as follows:
• Walnut Hill WWTP is being removed as a source. This location no longer produces
residuals and is used as a pump station.
• Maximum dry tonnage to be reduced to 8250 dry tons
• Several fields are being marked as "Delete". These include:
o CO-16-1 and CO-16-3
o CO-19-5 and CO-19-6
o CO-28-1,2,3 RECEIVED/NCDEQ/DWR
o CO-29-11
o CO-36-2
o PE-07-1,2,3 NOV 2 6 2U19
Non -Discharge
All other previously permitted fields are listed as "Renew". Permitting unit
Due to the minor modification classification there is no fee associated with this renewal.
This application package should contain all of the information necessary to complete the
requested renewal of the above mentioned permit. However, if you require additional
information or have further questions, please contact me at [phone] or
[e-mail]. Thank you in advance for the timely and efficient review of this renewal
application.
Sincerely,
Robert "Nate" Roth
284 Boger Road, Mocksville, NC 27028 • Phone: [phone] • Fax: [phone]

11
0

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 copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting 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.
Z The Applicant's Certification on Page 5 of this form shall be signed in accordance with 15A NCAC 02T .0 106b . 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 .0106fb).
® If this project is for a modification of an existing permit, submit one copy of the existing permit.
Please submit this application form at least 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).
i� Facility Classification New Permit Major Modification 1
—Major (land are permitted for > 300 acres) r $1,310 $395
_T 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)
R 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 I .0300)
® 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 P8&1&5%5&/bWare used for
the construction of the subject facilities.
Nov 2 6 1019
INSTRUCTIONS FOR FORM: RLAP 06-16
Non -Discharge
Permitting Unit
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.
Z. Submit the O&M Plan in accordance with 15A NCAC 02T .1110 and include at a minimum:
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;
® Names and titles of personnel responsible for conducting the inspections.
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.
Detailed description of inspection procedures including record keeping and actions to be taken by the inspector in the event
that noncompliance is observed.
Z Sampling and monitoring plan including the following information;
® Names and titles of personnel responsible for conducting the sampling and monitoring.
Detailed description of monitoring procedures including parameters to be monitored.
® 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.
❑ 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 11" 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 15A NCAC 02T .l 108
❑ 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

I.
J
K.
L.
M.
Project Evaluation and Receiver Site Management Plan (All New Application Packages or Modifications that include new sites)
❑ 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.
Hydrogeologic Report (All New Application Packages or Modifications involving increasing the total design capacity)
❑ Submit a detailed hydrogeologic evaluation in accordance with 15A NCAC 02T .1104(d)LC and current Division Policy
available at: bM://www.ncwater.orp/Rules Policies and Re ulations/. The document shall be signed, sealed and dated by a
qualified professional.
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 .1104()(2). For Modifications, submit an updated site map
specific to the modification(s) only.
❑ The design documents must include the following minimum items:
❑ 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;
❑ Specifications describing materials to be used, method of construction, and means for ensuring quality and integrity of the
finished product including leaking testing; and
Engineering calculations including hydraulic and pollutant loading, sizing criteria, hydraulic profile, total dynamic head
curve analysis for each pump, and irrigation design.
❑ Soil mapping units shown on all disposal sites.
Water Balance (All New Application Packages or Modifications that include new sites utilizing fixed irrigation facilities or
irrigation facilities fed through fined supply systems)
❑ Submit a completed and accurate water balance in accordance with 15A NCAC 02T .1104id)(5) and current Division Policy
available at: bqp://www.ncwater.orp-/.Rules Policies and Re ulations/.
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:
❑ Legal documentation of ownership (i.e., GIS, deed or article of incorporation), or
Written notarized intent to purchase agreement signed by both parties with a plat or survey map, or
❑ An easement running with the land specifically indicating the intended use of the property and meeting the requirements of
15A NCAC 02L .0107f 0, 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

DWR
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division of Water Resources 15A NCAC 02T .1100 — RESIDUALS LAND APPLICATION PROGRAM
FORM: RLAP 06-16
I. APPLICANT INFORMATION:
1. Applicant's name: Cape Fear Public Idlity Authori
❑ General Partnership ❑Privately -Owned Public Utility
Applicant type: 0 Individual Corporation
❑ Federal ❑ State Municipal ❑ County
Signature authority's name per 15A NCAC 02T .0106: James Flecther Title: Executive Director
Applicant's mailing address: 235 Governor Centre Drive
City: Wilmin ton State: NC Zip: 28403-
Telephone number: [phone] Email Address: [e-mail]
2. Consultant's name: RobertRoth License Number (for P.E.):
Affiliation: ❑ On Staff Retained (Firm: Synagro LLC )
Consultant's mailing address: 284 Boger Rd.
City: Iylocksville State: NC Zip: 27028-.
Telephone number: 336 790-1610 Email Address: [e-mail]
3. Agronomist's name:
License Number:
Affiliation: ❑ N/A ❑ On Staff
❑ Retained (Firm: _)
Agronomist's mailing address:
City: State:
Zip: -
Telephone number: (_—) —
Email Address:
4. Soil Scientist's name:
License Number:
RECEIVED/NCDE6UDWR
Affiliation: ❑ NIA ❑ On Staff
❑ Retained (Firm: N/A
Soil Scientist's mailing address: _
NOV 2 6 2019
City: State:
Zip: - .
Non -Discharge
Telephone number: (
Email Address:
Permitting Unit
5. Fee submitted: N/A (renewal (See Instruction B)
H. PERMIT INFORMATION:
1. Application is for (check all that apply): ❑ new, ❑ modified, 0 renewed permit
2. If this application is being submitted to renew or modify an existing permit, provide the following:
Permit number: Wa000127.1
Date of most -recently issued permit: 3/17/2016
Date of most -recently certified Attachment A (if different than the permit):
Date of most -recently certified Attachment B (if different than the permit):
FORM: RLAP 06-16 Page 1 of 5

III. RESIDUALS LAND APPLICATION PROGRAM INFORMATION:
1. Residuals Processing Facility's physical address: MultkJe sources. see RSC
City: Wibnin tgon State: NC Zip: -
Coordinates: Latitude: _ _ —ifLongitude: 0- -
Datum: lVAD 84 Level of accuracy: Second
Method of measurement: MAP
2. County where residuals land application program is headquartered: Cumberland
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 N. Roth Synagro 1001672
Back -Up ORC John A. Culp Synagro 100073
Additional Back -Up
ORCs
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:
4. Complete the following tables regarding management of the residuals land application program:
a. Plant Available Nitro en 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: 8250 dry tons per year.
PAN
Pounds of PAN per Dry Ton
(Weighted Average)
Pounds of PAN per Year
Surface
Incorporation
Surface
Incorporation
or Injection
or Injection
First -Year
10.4
13.96
85,833
115,203
Five -Year Maximum Adjusted
15.09
18.65
124,530
153,900
b. Land nnlication Site Use Summea: Summarize information regarding the land application sites as currently certified and
proposed for certification with this application:
Category
Use
Acres
Crops
Forest or Plantation
1426.84
Row Crops
958.2
Hay
0
Pasture
415.51
Total:
2800.55
Methods
Surface
2800.55
Incorporation or Injection
0
Total: 1 2800.55
Comments
FORM: RLAP 06-16 Page 2 of 5

c. Residuals Land A a Xcadon Summa : Determine the minimum acreage required to land apply the residuals as currently
certified and proposed for certification assuming the scenarios listed in the following table:
Assumed
Acres Required Using
Acres Required Using
Application Rate
First -Year PAN Concentrations
Five -Year Maximum Adjusted PAN
abs PAN/ac yr)
Concentrations
Surface Incorporation or
Surface Incorporation or
Injection
Injection
1716.7
2304.1
k 2490.6
3078.0
50
858.3
1152.0
1245.3
1539.0
100
572.2
768.0
830.2
1026.0
150
429.2
576.0
622.6
769.5
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.):
7. Specify type of residuals program (See Instruction F): 0 Non -dedicated [] Dedicated
If Dedicated, specify the following (check all that apply):
❑ Residuals program contains any land application site(s) that receives residuals at rates or frequencies greater than agronomic
rates, explain;
❑ Residuals program contains any land application site(s) that is used primarily for residuals disposal, and agricultural. crop
production is of secondary importance, explain;
❑ Residuals program contains any land application site(s) that receives residuals through fixed irrigation facilities or irrigation
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.
1 `®:
Residuals Source
Certification
V. LAND APPLICATION SITE INFORMATION: (Required for all new, renewed, or modified land application site)
Complete and submit the following Land Applications Site Certification and all associated documentation.
Land Application Siite
Certification.doc
FORM: RLAP 06-16 Page 3 of 5

Note: Item VI. Applicable to Dedicated Program with fixed irrigation Ustem only.
'I. DESIGN INFORMATION FOR FIXED IRRIGATION SYSTEM
1. The irrigation system is: ❑ Spray ❑ 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 021.0505io 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?
❑ Yes or ❑ 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:
Recommended Recommended
Soil Series Fields within Soil Area Loading Rate Loading Rate
(in/hr in/ r)
6. Design loading rates are equal or less than the loading rates recommended by Soil Scientist?
❑ Yes or ❑ 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):
Design Area Number of Maximum Application Design Annual Loading
Field / Zone ft2) Nozzles Rate allons/hr Rate (gallons/ !)
Total
Plan Sheet Specification
§Spra.yrrigation Design Element Number Pa a Number
diameter of nozzles ft
area of nozzles ft2
Nozzle capacity 1pm
Nozzle manufacturer / model /
Elevation of hijzhest nozzle ft
FORM: RLAP 06-16 Page 4 of 5

Applicant's Certification (signing authority must be in compliance with 15A NCAC 02T .0106):
.'he 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.
® Yes ❑ No, Explain;
Milton S Vann Wastewater Superintendent
(Signature Authority's Name — PLEASE PRINT) (Title)
attest that this application for Cape Fear Public Utility Authority
(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 § 143-215.65, 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
,xceed $10,000 as well as civil penalties up to $25,000 per violation.
Signature: _ r
Date: of Zo 1
FORM: RLAP 06-16 Page 5 of 5

OPERATIONS AND MAINTENANCE PLAN
RESIDUALS LAND APPLICATION FOR WQ0001271 (Cape Fear Public Utility Authority)
Operational Functions
The operation function of this project is going to involve the dewatering process of the Northside WWTP, Sweeney WTP
is directly piped to the Northside WWTP for dewatering. Once dewatered, Northside WWTP, and Sweeney WTP are
transported by truck to the covered storage pad at the Southside WWTP. Southside WWTP is dewatered and conveyed
to the covered storage pad at the facility. All WWTP and WTP dewatered biosolids are blended together at Southside
WWTP storage pad before land applied. It is going to be spread at agronomic rates that are determined by the nutrient
and metal sample that is current for that monitoring period. It is going to be spread with a cake applicator that will
spread the material in such a way to achieve a consistent spread pattern. The material is going to be land applied on
fields that have grass growing on them that are going to either be grazed or cut for hay for animal feed or row crops to
be planted on them and used for animal feed.
SAFETY MEASURES
Synagro believes in operating in a safety conscious manner and is has all employees participate in quarterly online safety
course that are designed to help its employees recognize safety issues and take steps to prevent accidents from
occurring. In addition all Synagro employees have the authority to stop operations if they think any aspect of the
operation is going to cause environmental or personal harm.
Maintenance Schedule
Synagro will follow the maintenance schedule as recommended by the Synagro fleet manager for the equipment
necessary to complete the job.

OPERATIONS AND MAINTENANCE PLAN
RESIDUALS LAND APPLICATION FOR WQ0001271
Sampling Plan
Sampling for this project consists of sampling the residuals during the time that land application is occurring. This will
result in one round of sampling to occur before land application commences in order to insure that the residuals are
suitable for land application. Based on the dry tonnage of this plant this will be one sample for all parameters 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
Tetrachloroethylene (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 Monitoring Frequency
7
(short tons per year) (Established in 40 CFR 503 and 15A NCAC 02T
<319
=>3
=>16,500
Aluminum
Ammonia -Nitrogen
Arsenic
Cadmium
Calcium
Copper
Lead
Sodium Adsorption Ratio (SAR)
1 time per yea
Quarter (4 times
1 every 60 days (6 times per year) _
1 every month (12 times per year)
Magnesium PH
Mercury Plant Available Nitrogen (calculation)
Molybdenum Selenium
Nickel Sodium
Nitrate -Nitrite Nitrogen %Total Solids
Phosphorous Total Kjeldahl Nitrogen
Potassium Zinc
In order to meet pathogen and vector requirements the material form Northside and Southside WWTP will be held in anaerobic
digesters for the specified time and temperature to satisfy this requirement.. Sweeny WTP is exempt from pathogen and vector
attraction requirements due to it only being WTP material. The samples that will be pulled are a TCLP, nutrient and metals sample
in order to prove the material is compliant for land application and will be used in conjunction with the time and temperature
data supplied by CFPUA. The nutrient and metal and TCLP sample will be collected randomly and consist of at least 30 individual
samples mixed together in order to get the composite sample for these parameters. This should take care of any seasonal
fluctuations in the material.
The following people are responsible for sampling:
Milton S. Vann or his designee.

OPERATIONS AND MAINTENANCE PLAN
RESIDUALS LAND APPLICATION FOR WQ0001271(Cape Fear Public Utility Authority)
Inspection Plan
Inspections for the land application of residuals will be conducted on a weekly basis at the land application site during the land
application activities of this project. The inspection frequency is based on the time frame that it is going to take to complete the
project and the amount of dry tons to be land applied from this facility. 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 Operations and Technical staff.
2. Checking the calculated loads to insure the correct amount of residuals are being land applied.
3. Insure that all manned equipment has a copy of the spill control plan, the permit, and the operations and maintenance
plan.
4. Insure that the field has been flagged properly and that all buffers are being adhered to.
S. Insure that the Crop and Landowner Verification form has been filled out.
6. Verifying that the correct number samples of the residuals have been taken and that it meets the criteria for land
application.
7. The records will be kept in the project files in the respective office for the project.
8. The Permittee or inspector shall report by telephone to the Raleigh Regional Office by Telephone at 919-791-4200 as
soon as possible but no later than 24 hours after or the next working day following the occurrence or the 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 to surface waters.
• Any time that self -monitoring 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 1-
800-662-7956,1-800-858-0368, or 1-919-733-3300. These numbers are to be called in the event of a release to
surface waters, imminent failure of a storage system when the event occurs outside of normal business hours.
• Within 5 days of the first notice of on 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:
Milton S. Vann or his designee.

SPILL RESPONSE PLAN
"ROJECT: Cave Fear Public Utility Authority Permit WQ0001271
IN THE UNLIKELY EVENT OF A SPILL. THE FOLLOWING ACTIONS SHALL BE TAKEN
IMMEDIATELY:
1. MANAGEMENT OF SPILL CLEAN-UP ACTIVITIES:
The Operations Manager shall take immediate charge and initiate clean-up activities. Contractor labor and equipment is
to be utilized. In the event additional labor and equipment is required, assistance may be requested from the Cape Fear
Public Utility Authority, 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 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 Operations Manager or assistant will notify the Central office, and they will
then be responsible for notifying other key personnel.
7. REPORTING:
CFPUA personnel will notify the Raleigh Regional Office by Telephone at 919-791-4200 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. Contractor personnel will file a written report to the Raleigh 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 (800-
662-7956 or 800-858-0368 or 919-733-3300)

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State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
Division of Water Resources RESIDUALS SOURCE CERTIFICATION
INSTRUCTIONS FOR FORM: RSC 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
sunnortine documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Unit
General — This certification provides detailed information of residuals source generating facility and its residuals quality for land
application, distribution, or disposal in accordance with 15A NCAC 02T .1100. Do not submit this certification for review without
a corresponding application form (FORM: RLAP 11-15, FORM: DCAR 11-15, or FORM: SDR 11-15).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Residuals Source Certification (FORM: RSC 11-15):
® Submit the completed and appropriately executed Residuals Source Certification (FORM: RSC 11-15) 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 a separate certification for each source facility.
® For modified permits, submit a separate certification for only those facilities that are affected by the proposed modification.
® Complete the residuals source facility summary page. List all new, renewed, or modified facilities.
E. Residuals Source -Generating Facility Information:
® For each source facility, attach the following:
® Vicinity map - A vicinity map that shows the location of the facility and meets all of the criteria in the "Map -Guidance for
Residuals Land Application Permits".
® Process flow diagram and/or narrative - A detailed narrative and/or process flow diagram that describes how the residuals
are to be generated, treated, processed, and stored at the facility.
® Quantitative justification for residuals production rate - A quantitative justification for the value provided in Item I. S.
Ensure that the amount of residuals listed is the maximum amount expected to be generated by the facility for the life of
the permit. In addition, ensure that this amount is equivalent to that which is actually to be land applied, distributed,
and/or disposed, including any chemicals, amendments, or other additives that are added to the residuals during
processing.
® Sampling plan - A detailed sampling plan for the residuals source -generating facility. Ensure that the plan identifies
sampling points, sampling frequency, sample type, as well as the Division -certified laboratory to be used. In addition,
ensure that the plan details how the facility and/or the residuals are monitored for any applicable pathogen reduction and
vector attraction reduction requirements. Note that all sampling and monitoring must be completed on the residuals as
they are to be land applied, distributed, and/or disposed.
C. Residuals Quality Information:
® For each source facility, attach the following:
® Laboratory analytical reports and operational data - reports for all laboratory analyses used to complete this certification.
® Documentation that the facility complies and/or the residuals comply with any applicable pathogen reduction and vector
attraction reduction requirements.
® For new facility that may have not yet been constructed and analytical results of residuals cannot be obtained, please
attach analytical results of residuals generated from a similar facility along with the description of similarities of the two
facilities.
INSTRUCTIONS FOR FORM: RSC 06-16 Page 1 of 1

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Division of Water Resources
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State of North Carolina
Department of Environmental Quality
Division of Water Resources
RESIDUALS SOURCE CERTIFICATION
FORM: RSC 06-16
RESIDUALS SOURCE -GENERATING FACILITY INFORMATION (See Instruction B.):
1. Facility Name: filorthside WWTP
2. Facility permit holder is: Federal, 0 State, M. Local Government, or 0 Private.
Facility permit issued by: Div. of Water Resources, 0 Div. of Environmental Health,
or f ] Other (explain: ).
3. Facility contact person and title: Jeff ermak. Northside WWTP SuMerviss
Complete mailing address: 235 Government Center Drive
City: Wilmington State: NC Zip: n4031
Telephone number: (910) dh-= 562 E-mail address: [e-mail]
4. Facility physical address: 2311 N. 23rd Street
City: ilming� State: NC Zip: 284R
Coordinates: Latitude: '15` 46" Longitude:
Datum: NAD 84; Level of accuracy: 'Second
Method of measurement: lm"I
5. Purpose of the facility:
treatment of municipal wastewater, 0 treatment of 100% domestic wastewater,
0, treatment of potable water, treatment of 100% industrial wastewater,
0 treatment of industrial wastewater mixed with domestic wastewater,
(approximate percentages:. % industrial and .' % domestic)
other (explain:.)
6. Does the facility have an approved pretreatment program: Yes No
7. Facility permitted/design flow: ;'16.0 MGD and facility average daily flow: ', A.
8. Average amount of residuals being generated at this facility 4.568 all sources combined dry tons per year.
9. Specify the following regarding treatment and storage volumes available at the facility:
Type and volume of residuals treatment: 2- 800,000 gal Anaerobic Digesters. 3- 400,000 al Anaerobic Digesters
Type and volume of residuals storage (i.e., outside of residuals treatment units): 30 days at Southside WWTP storggUad
RESIDUALS QUALITY INFORMATION (See Instruction C.):
1. Specify if residuals are regulated under:
40 CFR Part 503 or 40 CFR Part 257.
Note: Only residuals that are generated during domestic/municipal wastewater treatment processes are regulated under 40
CFR Part 503, otherwise, the residuals are regulated under 40 CFR Part 257.
2. Specify if residuals are defined under 15A NCAC 02T.1102 6 as:
Biological Non -Biological
Note: Biological residuals are residuals that have been generated during the treatment of domestic wastewater, animal
processing wastewater, or the biological treatment of industrial wastewater (biological treatment is a system that utilizes
biological processes including lagoons, activated sludge systems, extended aeration systems, and fixed film systems).
FORM: RSC 06-16 Page 1 of 5

3. Hazardous Waste Determination: Complete the following to demonstrate that the residuals are non -hazardous under
RCRA: (Note - this item does not have to be completed for facilities that are less than 0.5 MGD in design flow that treat
100% non -municipal, domestic wastewater only)
a. Are the residuals listed in 40 CFR §261.31-§261.33: ❑ yes 01 no.
If yes, list the number(s):
b. Specify whether or not the residuals exhibit any of the characteristics defined by 40 CFR §261.21-
261.24: El yes 0 no.
Fill in the following tables with the results of the latest toxicity characteristic leaching procedure (TCLP) analysis as
well as those for corrosivity, ignitability, and reactivity:
Laboratory: Sheal Env. Labs and Date of analysis: 5/0Q2019,
Passed corrosivity test: yes ❑ no. pH: s.u. (2 < pH < 12.5)
Passed ignitability test: yes ]: no. Flashpoint: >2O OF (> 140°F)
Passed reactivity test: f yes ❑no. HCN: ND, mg/kg (<250) & H2S: kO i mg/kg (<500)
TCLP Parameter
Limit
Result
TCLP Parameter
Limit
Result
(Mg/1)
(m9/1)
(Mg/1)
(mg/1)
Arsenic
5.0
ND
Hexachlorobenzene
0.13
ND
Barium
100.0
0.27
Hexachloro-1,3-Butadiene
0.5
ND
Benzene
0.5
ND
Hexachloroethane
3.0
ND
Cadmium
1.0
ND
Lead
5.0
ND
Carbon Tetrachloride
0.5
ND
Lindane
0.4
ND
Chlordane
0.03
ND
Mercury
0.2
ND
Chlorobenzene
100.0
ND
Methoxychlor
10.0
ND
Chloroform
6.0
ND
Methyl Ethyl Ketone
200.0
ND
Chromium
5.0
ND
Nitrobenzene
2.0
ND
m-Cresol
200.0
ND
Pentachlorophenol
100.0
ND
o-Cresol
200.0
ND
Pyridine
5.0
ND
p-Cresol
200.0
ND
Selenium
1.0
ND
Cresol
200.0
ND
Silver
5.0
ND
2,4-D
10.0
ND
Tetrachloroethylene
0.7
ND
1,4-Dichlorobenzene
7.5
ND
Toxaphene
0.5
ND
1,2-Dichloroethane
0.5
ND
Trichloroethylene
0.5
ND
1,1-Dichloroethylene
0.7
ND
2,4,5-Trichlorophenol
400.0
ND
2,4-Dinitrotoluene
0.13
ND
2,4,6-Trichlorophenol
2.0
ND
Endrin
0.02
ND
2,4,5-TP (Silvex)
1.0
ND
Heptachlor and its Hydroxide
00
0.8
ND
Vinyl Chloride
0.2
ND
FORM: RSC 06-16 Page 2 of 5

4. Metals Determination: Complete one of the following tables (i.e., as applicable) to demonstrate that the residuals do not
violate the ceiling concentrations for metals regulated under 15A NCAC 02T .1105.
a. For Distribution/Land Application: Fill in the following table with the results of the latest analyses (i.e., on a dry weight
basis) for the following metal parameters:
Laboratory: iWaXpoint Anal ical and Date of analysis: 02-& 9
Parameter
Ceiling
Concentration Limits
(ClassA & ClassB)
(mg1kg)
Monthly Average
Concentration Limits
(Class A Only)
(mglkg)
41
Result
(mglkg)
Arsenic
75
6.96
Cadmium
85
39
<1.0
Copper
4,300
1,500
133
Lead
840
300
21.3
Mercury
57
17
0.189
Molybdenum
75
n/a
4.02
Nickel
420
420
21.8
Selenium
100
100
<5.0
Zinc
7,500
2,800
370
b. For Surface Disposal Unit (landfill): Fill in the following table with the results of the latest analyses (i.e., on a dry weight
basis) for the following metal parameters:
Laboratory: and Date of analysis:
Distance from Disposal
Unit to Boundary to
Closest Property Line
(meters, check one)
❑ >0but <25
>25but<50
[] > 50 but < 75
0 > 75 but < 100
>100but <125
> 125
Result (mg/kg)
FORM: RSC 06-16
Arsenic I Chromium i Nickel
(mg1kg)
(mglkg)
(mg/kg)
30
200
210
34
220
240
39
260
270
46
300
320
53
360
390
62
450
420
Page 3 of 5

5. Nutrient/Micronutrient Determination: Complete the following:
a. Total solids: ff i %.
b. Fill in the following table with the results of the latest analyses (i.e., on a dry weight basis) for the following nutrient and
C.
d.
micronutrient parameters:
Laboratory: ?.Wa}�oint Analytical and Date of analysis: t/26/19
TotalKjeldahlNitrogen �� ia,avv
Using the results listed in Item IL 5b. above, calculate the sodium adsorption ration (SAR): 0.33
[Note: If residuals contain SAR of 10 or higher, the applicant shall obtain recommendations from the local Cooperative
Extension Office, the Department of Agriculture and Consumer Services, the Natural Resource Conservation _Service, a
North Carolina Licensed Soil Scientist, or an agronomist, prior to land application of residuals. The recommendations shall
address the sodium application rate, soil amendments (e.g., gypsum, etc.), or a mechanism for maintaining site integrity
and conditions conducive to crop growth].
Specify the mineralization rate to be used in calculating the plant available nitrogen (PAN) of the residuals: A %. This
rate is a (check one): n'. default value, or 0' actually established.
If the residuals are not generated from the treatment of municipal or domestic wastewater, explain or provide technical
justification as to why the selected default value is appropriate to be applied to these residuals:
Calculate the PAN for the residuals (i.e., on a dry weight basis) and fill the results in the following table:
Application Method
Surface
Injection/Incorporation
First (131) Year PAN
(mg/kg)
5,202
6,982
Five -Year
Maximum Adjusted PAN
(mg/kg)
7,547
9,327
6. Other Pollutants Determination: Specify whether or not there are any other pollutants of concern in the residuals and provide
the results of the latest analyses: i"
FORM: RSC 06-16
Page 4 of 5

7. Pathogen Reduction: Per 15A NCAC 02T.1106. specify how residuals will meet the pathogen reduction requirements:
a. For Distribution/Land Application of Class A or Equivalent:
A fecal coliform density that is demonstrated to be less than 1,000 MPN per gram of total dry solids,
or
A salmonella sp. density that is demonstration to be less than 3 MPN per 4 grams of total dry solids.
AND one of the followings (except for non -biological residuals):
;Q Alternative 1 [15A NCAC 02T. 1 106(b)(3)(A)] - Time/Temperature Compliance.
0 Alternative 2 [15A NCAC 02T.1106(b)(3)(B)] - Alkaline Treatment.
Alternative 3 [15A NCAC 02T.1106(b)(3)(C)] - Prior Testing for Enteric Virus/Viable Helminth Ova.
Alternative 4 [15A NCAC 02T.I 106(b)(3)(D)] - No Prior Testing for Enteric Virus/Viable Helminth Ova.
Alternative 5 [15A NCAC 02T.1106(b)(3)(E)-(K)] - Process to Further Reduce Pathogens (PFRP).
Specify one: ❑', composting, heat drying, ❑: heat treatment,
b thermophilic aerobic digestion,beta ray irradiation,
]i gamma ray irradiation, or Q pasteurization.
b. For Land Application of Class B:
f' Alternative 1 [15A NCAC 02T.1106(c)(1)] - Fecal Coliform Density Demonstration.
0 Alternative 2 [15A NCAC 02T.1106(c)(2)] - Process to Significantly Reduce Pathogens (PSRP).
Specify one: aerobic digestion, 0, air drying, ;Eg anaerobic digestion,
❑ composting, or [E lime stabilization.
c. For Sur ace Dis osal:
Select One of the Class A or Equivalent Pathogen Reduction Alternatives in Item 11. 7a. above.
Select One of the Class B or Equivalent Pathogen Reduction Alternatives in Item II. 7b. above.
Exempt - If Daily Cover Alternative is chosen in Item II.8. below [15A NCAC 02T.1106(a)(2)].
Q Not Applicable - Non -Biological Residuals with NO Domestic Wastewater Contribution.
8. Vector Attraction Reduction VAR : Per 15A NCAC 02T.1107, specify how residuals will meet the VAR requirements:
Alternative 1 [15A NCAC 02T.1107(a)(1)] - 38% Volatile Solids Reduction (Aerobic/Anaerobic Digestion).
Alternative 2 [15A NCAC 02T.1107(a)(2)] - 40-Day Bench Scale Test (Anaerobic Digestion).
Alternative 3 [15A NCAC 02T.1107(a)(3)] - 30-Day Bench Scale Test (Aerobic Digestion).
[] Alternative 4 [15A NCAC 02T.1107(a)(4)] - Specific Oxygen Uptake Rate Test (Aerobic Digestion).
] Alternative 5 [15A NCAC 02T.1107(a)(5)] - 14-Day Aerobic Processes.
Alternative 6 [15A NCAC 02T.1107(a)(6)] - Alkaline Stabilization.
[� Alternative 7 [15A NCAC 02T. 1 107(a)(7)] - Drying of Stabilized Residuals.
Alternative 8 [15A NCAC 02T. 1 107(a)(8)] - Drying of Unstabilized Residuals.
Alternative 9 [15A NCAC 02T.I 107(a)(9)] - Injection.
Alternative 10 [15A NCAC 02T. I 107(a)(10)] - Incorporation.
Alternative for Surface Disposal Units Only - Soil/Other Material Cover [15A NCAC 02T.1107(b)(2)].
Q Not Applicable - Non -Biological Residuals with NO Domestic Wastewater Contribution.
Note: For animal processing residuals, only alternatives 9 or 10 may be chosen due to the nuisance conditions that typically
occur when these residuals are applied and left on the land surface.
FORM: RSC 06-16 Page 5 of 5

VICINITY MAP
NCDOT 9 District 3 +'
District Engineer &... U"
U"
New Hanover
Humane Society T
Superior Distribution
Roofing & Building...
Prime Storage 9
IV2311 North 23rd Street
University of Norte
Carolina Wilmington
SRS DISTRIBUTION
m
704
Go, gle
COUNTY: New Hanover OWNER(S): CFPUA - Northside WWTP

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Residuals Sampling Plan
Cape Fear Public Utility Authority Land Application Program
Northside/ Southside Wastewater Treatment Plants
Nutrients and Metals Analysis
Sampling Point: Southside WWTP Storage Pad
Sampling Frequency: Based on Dry Tons Land Applied
Sample Type: Grab
Lab: Waypoint Analytical Virginia, Inc.
Pathoacn
Sampling Point: Southside and Northside WWTP
Sampling Frequency: Based on Dry Tons Land Applied
Sample Type: Time and Temperature
Lab: CFPUA Lab
Vector
TCLP
Sampling Point: Southside and Northside WWTP
Sampling Frequency: Based on Dry Tons Land Applied
Sample Type: 38% VSR
Lab: CFPUA Lab
Sampling Point: Southside WWTP Storage Pad
Sampling Frequency: Annually
Sample Type: Grab
Lab: Summit Environmental Technologies, Inc

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State of North Carolina
Department of Environmental Quality
DWR.Division of Water Resources
Division of Water Resources RESIDUALS SOURCE CERTIFICATION
INSTRUCTIONS FOR FORM: RSC 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 a Permitting Unit
General — This certification provides detailed information of residuals source generating facility and its residuals quality for land
application, distribution, or disposal in accordance with 15A NCAC 02T .1100. Do not submit this certification for review without
a corresponding application form (FORM: RLAP 11-15, FORM: DCAR 11-15, or FORM: SDR 11-15).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Residuals Source Certification (FORM: RSC 11-15):
® Submit the completed and appropriately executed Residuals Source Certification (FORM: RSC 11-15) 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 a separate certification for each source facility.
® For modified permits, submit a separate certification for only those facilities that are affected by the proposed modification.
® Complete the residuals source facility summary page. List all new, renewed, or modified facilities.
B. Residuals Source -Generating Facility Information:
® For each source facility, attach the following:
® Vicinity map - A vicinity map that shows the location of the facility and meets all of the criteria in the ",Map Guidance for
Residuals Land Application Permits".
® Process flow diagram and/or narrative - A detailed narrative and/or process flow diagram that describes how the residuals
are to be generated, treated, processed, and stored at the facility.
® Quantitative justification for residuals production rate - A quantitative justification for the value provided in Item I. S.
Ensure that the amount of residuals listed is the maximum amount expected to be generated by the facility for the life of
the permit. In addition, ensure that this amount is equivalent to that which is actually to be land applied, distributed,
and/or disposed, including any chemicals, amendments, or other additives that are added to the residuals during
processing.
® Sampling plan - A detailed sampling plan for the residuals source -generating facility. Ensure that the plan identifies
sampling points, sampling frequency, sample type, as well as the Division -certified laboratory to be used. In addition,
ensure that the plan details how the facility and/or the residuals are monitored for any applicable pathogen reduction and
vector attraction reduction requirements. Note that all sampling and monitoring must be completed on the residuals as
they are to be land applied, distributed, and/or disposed.
C. Residuals Quality Information:
® For each source facility, attach the following:
® Laboratory analytical reports and operational data - reports for all laboratory analyses used to complete this certification.
® Documentation that the facility complies and/or the residuals comply with any applicable pathogen reduction and vector
attraction reduction requirements.
® For new facility that may have not yet been constructed and analytical results of residuals cannot be obtained, please
attach analytical results of residuals generated from a similar facility along with the description of similarities of the two
facilities.
INSTRUCTIONS FOR FORM: RSC 06-16 Page 1 of I

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State of North Carolina
IDWRDepartment of Environmental Quality
Division of Water Resources
Division of Water Resources RESIDUALS SOURCE CERTIFICATION
FORM: RSC 06-16
I. RESIDUALS SOURCE -GENERATING FACILITY INFORMATION (See Instruction B.):
1. Facility Name: Southside WWTP,
2. Facility permit holder is: ❑ Federal, 0 State, Local Government, or ❑ Private.
Facility permit issued by: Div. of Water Resources, ❑ Div. of Environmental Health,
or ❑ Other (explain:
3. Facility contact person and title: §teven S ers Southside WWTP Su ervisor:.
Complete mailing address: 235 Government Center Drive
City: Wilmin igton State: TCG zip: 284031
Telephone number: (910) �32-575 E-mail address: Steven. Styers ,cfpua.orc
4. Facility physical address: 3436 River Road
City: Wilmington State: NO Zip: 1'�28412-i
Coordinates: ' Latitude: 4° ;04' S6" Longitude: 77P '56''44"
Datum: NAD 84i Level of accuracy: Second
Method of measurement: ka
5. Purpose of the facility:
treatment of municipal wastewater, ❑ treatment of 100% domestic wastewater,
❑ treatment of potable water, ❑' treatment of 100% industrial wastewater,
❑ treatment of industrial wastewater mixed with domestic wastewater,
(approximate percentages: % industrial and % domestic)
❑ other (explain:. , ).
6. Does the facility have an approved pretreatment program: Yes ❑ No
7. Facility permitted/design flow: 12.0 MGD and facility average daily flow: '.6_7MGD
8. Average amount of residuals being generated at this facility 4,568 all sources combined dry tons per year.
9. Specify the following regarding treatment and storage volumes available at the facility:
Type and volume of residuals treatment: 1-1,000,OOOa1 Anaerobic Digester: 2-400,000-gal Anaerobic Digesters Type
and volume of residuals storage (i.e., outside of residuals treatment units): 30 days at Southside WWTP storage pad
II. RESIDUALS QUALITY INFORMATION (See Instruction C.):
1. Specify if residuals are regulated under:
40 CFR Part 503 or ❑ 40 CFR Part 257.
Note: Only residuals that are generated during domestic/municipal wastewater treatment processes are regulated under 40
CFR Part 503, otherwise, the residuals are regulated under 40 CFR Part 257.
2. Specify if residuals are defined under 15A NCAC 02T.1102(6) as:
0,' Biological ❑ Non -Biological
Note: Biological residuals are residuals that have been generated during the treatment of domestic wastewater, animal
processing wastewater, or the biological treatment of industrial wastewater (biological treatment is a system that utilizes
biological processes including lagoons, activated sludge systems, extended aeration systems, and fixed film systems).
FORM: RSC 06-16 Page 1 of 5

3. Hazardous Waste Determination: Complete the following to demonstrate that the residuals are non -hazardous under
RCRA: (Note - this item does not have to be completed for facilities that are less than 0.5 MGD in design flow that treat
100% non -municipal, domestic wastewater only)
a. Are the residuals listed in 40 CFR §261.31-§261.33: Q yes no.
If yes, list the number(s):
b. Specify whether or not the residuals exhibit any of the characteristics defined by 40 CFR §261.21-
261.24: El- yes 0 no.
Fill in the following tables with the results of the latest toxicity characteristic leaching procedure (TCLP) analysis as
well as those for corrosivity, ignitability, and reactivity:
Laboratory: Shealy Env. Labs.' and Date of analysis: 'S/01/2019,
Passed corrosivity test: 00 yes no. pH: s.u. (2 < pH < 12.5)
Passed ignitability test: 0 yes Q no. Flashpoint: >200 °F (> 140°F)
Passed reactivity test: M yes Ono. HCN: ND mg/kg (<250) & H2S: ;60:0' mg/kg (<500)
TCLP Parameter
Limit
Result
TCLP Parameter
Limit
Result
(mg/1)
(M9/1)
(mg/1)
(mg/l)
Arsenic
5.0
ND
Hexachlorobenzene
0.13
ND
Barium
100.0
0.27
Hexachloro-1,3-Butadiene
Hexachloroethane
Lead
Lindane
0.5
3.0
5.0
0.4
ND
ND
ND
ND
Benzene 0.5 1 ND
Cadmium 1.0 ND
Carbon Tetrachloride 0.5 ND
Chlordane
0.03
ND
Mercury
0.2
ND
Chlorobenzene
100.0
ND
Methoxychlor
10.0
ND
Chloroform
6.0
ND
Methyl Ethyl Ketone
200.0
ND
Chromium
5.0
ND
Nitrobenzene
2.0
ND
m-Cresol
200.0
ND
Pentachlorophenol
100.0
ND
o-Cresol
200.0
ND
Pyridine
5.0
ND
p-Cresol
200.0
ND
Selenium
.1.0
ND
Cresol
200.0
ND
Silver
5.0
ND
2,4-D
10.0
ND
Tetrachloroethylene
0.7
ND
1,4-Dichlorobenzene
7.5
ND
Toxaphene
0.5
ND
1,2-Dichloroethane
0.5
ND
Trichloroethylene
0.5
ND
1, 1 -Dichloroethylene
0.7
ND
2,4,5-Trichlorophenol
400.0
ND
2,4-Dinitrotoluene
0.13
ND
2,4,6-Trichlorophenol
2.0
ND
Endrin
0.02
ND
2,4,5-TP (Silvex)
1.0
ND
Heptachlor and its Hydroxide
0.008
ND
Vinyl Chloride
0.2
ND
FORM: RSC 06-16 Page 2 of 5

4. Metals Determination: Complete one of the following tables (i.e., as applicable) to demonstrate that the residuals do not
violate the ceiling concentrations for metals regulated under 15A NCAC 02T .1105.
a. For Distribution/Land Application: Fill in the following table with the results of the latest analyses (i.e., on a dry weight
basis) for the following metal parameters:
Laboratory: Waypoint Analytical and Date of analysis: ) /26/19
Parameter Ceiling Monthly Average
Concentration Limits Concentration Limits
(ClassA & ClassB) (Class A Only)
(mg/kg) (mg/kg)
Arsenic 75 41
Result
(mg/kg)
6.96
Cadmium
85
39
<1.0
Copper
4,300
1,500
133
Lead
840
300
21.3
Mercury
57
17
0.189
Molybdenum
75
n/a
4.02
Nickel
420
420
21.8
Selenium
100
100
<5.0
Zinc
7,500 2,800
370
b. For Surface Disposal Unit (landfill: Fill in the following table with the results of the latest analyses (i.e., on a dry weight
basis) for the following metal parameters:
Laboratory:. and Date of analysis:
Distance from Disposal
Unit to Boundary to
Closest Property Line
(meters, check one)
Arsenic
(mg/kg)
Chromium
(mg/kg)
Nickel
(mg/kg)
❑ > 0 but < 25
30
200
210
> 25 but < 50
34
220
240
[} > 50 but < 75
39
260
270
> 75 but < 100
46
300
320
❑ > 100 but < 125
53
360
390
❑ > 125
62
450
420
Result (mg/kg)
FORM: RSC 06-16 Page 3 of 5

5. Nutrient/Micronutrient Determination: Complete the following:
a. Total solids: r7.4 %.
b. Fill in the following table with the results of the latest analyses (i.e., on a dry weight basis) for the following nutrient and
micronutrient parameters:
Laboratory: W'W oint Analytical and Date of analysis: E/26/19
c. Using the results listed in Item H. 5b. above, calculate the sodium adsorption ration (SAR): 0.33
[Note: If residuals contain SAR of 10 or higher, the applicant shall obtain recommendations from the local Cooperative
Extension Office, the Department of Agriculture and Consumer Services, the Natural Resource Conservation Service, a
North Carolina Licensed Soil Scientist, or an agronomist, prior to land application of residuals. The recommendations shall
address the sodium application rate, soil amendments (e.g., gypsum, etc.), or a mechanism for maintaining site integrity
and conditions conducive to crop growth].
d. Specify the mineralization rate to be used in calculating the plant available nitrogen (PAN) of the residuals: 3420 %. This
rate is a (check one): 0, default value, or E! actually established.
If the residuals are not generated from the treatment of municipal or domestic wastewater, explain_ or provide technical
justification as to why the selected default value is appropriate to be applied to these residuals: ;
e. Calculate the PAN for the residuals (i.e., on a dry weight basis) and fill the results in the following table:
Application Method First (1st Year PAN Five -Year
Maximum Adjusted PAN
(mglkg) (mg1kg)
Surface 5,202 7,547
Injection/Incorporation 6,982 9,327
6. Other Pollutants Determination: _Specify whether or not there are any other pollutants of concern in the residuals and provide
the results of the latest analyses: N/A
FORM: RSC 06-16 Page 4 of 5

7. Pathogen Reduction: Per 15A NCAC 02T.1106, specify how residuals will meet the pathogen reduction requirements:
a. For Distribution/Land Application of Class A or Equivalent:
A fecal coliform density that is demonstrated to be less than 1,000 MPN per gram of total dry solids,
or
❑ A salmonella sp. density that is demonstration to be less than 3 MPN per 4 grams of total dry solids.
AND one of the followings (except for non -biological residuals):
Alternative 1 [I5A NCAC 02T.I 106(b)(3)(A)] - Time/Temperature Compliance.
❑ Alternative 2 [15A NCAC 02T.I 106(b)(3)(B)] - Alkaline Treatment.
Alternative 3 [15A NCAC 02T.1106(b)(3)(C)] - Prior Testing for Enteric Virus/Viable Helminth Ova.
Alternative 4 [15A NCAC 02T. I 106(b)(3)(D)] - No Prior Testing for Enteric Virus/Viable Helminth Ova.
[]' Alternative 5 [15A NCAC 02T.I106(b)(3)(E)-(K)] - Process to Further Reduce Pathogens (PFRP).
Specify one: composting, ❑ heat drying, ❑ heat treatment,
❑' thermophilic aerobic digestion, ❑' beta ray irradiation,
gamma ray irradiation, or ❑; pasteurization.
b. For Land Application of Class B:
0', Alternative 1 [15A NCAC 02T. I 106(c)(1)] - Fecal Coliform Density Demonstration.
❑ Alternative 2 [15A NCAC 02T.1106(c)(2)] -Process to Significantly Reduce Pathogens (PSRP).
Specify one: aerobic digestion, ❑ air drying, N anaerobic digestion,
I composting, or ❑ lime stabilization.
c. For Surface Disposal:
Select One of the Class A or Equivalent Pathogen Reduction Alternatives in Item II. 7a. above.
❑ Select One of the Class B or Equivalent Pathogen Reduction Alternatives in Item II. 7b. above.
Exempt -If Daily Cover Alternative is chosen in Item H.8. below [15A NCAC 02T.1106(a)(2)].
Not Applicable - Non -Biological Residuals with NO Domestic Wastewater Contribution.
8. Vector Attraction Reduction (VAR): Per 15A NCAC 02T.1107, specify how residuals will meet the VAR requirements:
Alternative 1 [15A NCAC 02T.1107(a)(1)] - 38% Volatile Solids Reduction (Aerobic/Anaerobic Digestion).
Alternative 2 [15A NCAC 02T.1107(a)(2)] - 40-Day Bench Scale Test (Anaerobic Digestion).
Alternative 3 [15A NCAC 02T.1107(a)(3)] - 30-Day Bench Scale Test (Aerobic Digestion).
Alternative 4 [15A NCAC 02T. 1 107(a)(4)] - Specific Oxygen Uptake Rate Test (Aerobic Digestion).
Alternative 5 [15A NCAC 02T.I 107(a)(5)] - 14-Day Aerobic Processes.
n Alternative 6 [15A NCAC 02T. 1 107(a)(6)] - Alkaline Stabilization.
Alternative 7 [15A NCAC 02T.I 107(a)(7)] - Drying of Stabilized Residuals.
Alternative 8 [15A NCAC 02T. 1 107(a)(8)] - Drying of Unstabilized Residuals.
Alternative 9 [15A NCAC 02T.1107(a)(9)] - Injection.
Alternative 10 [15A NCAC 02T.1107(a)(10)] - Incorporation.
Alternative for Surface Disposal Units Only - Soil/Other Material Cover [15A NCAC 02T. 1 107(b)(2)].
❑I Not Applicable - Non -Biological Residuals with NO Domestic Wastewater Contribution.
Note: For animal processing residuals, only alternatives 9 or 10 may be chosen due to the nuisance conditions that typically
occur when these residuals are applied and left on the land surface.
FORM: RSC 06-16 Page 5 of 5

VICINITY Mar SYNAGRO
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Wilmington
Southside'Wasteont rqo Public Building-s
Treatment aMt
Waste Management -
Wilmington Hauling
COUNTY: New Hanover OWNER(S): CFPUA— Southside WWTP

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Residuals Sampling Plan
Cape Fear Public Utility Authority Land Application Program
Northside/ Southside Wastewater Treatment Plants
Nutrients and Metals Analvsis
Sampling Point: Southside WWTP Storage Pad
Sampling Frequency: Based on Dry Tons Land Applied
Sample Type: Grab
Lab: Waypoint Analytical Virginia, Inc.
Pathogen
Vector
TCLP
Sampling Point: Southside and Northside WWTP
Sampling Frequency: Based on Dry Tons Land Applied
Sample Type: Time and Temperature
Lab: CFPUA Lab
Sampling Point: Southside and Northside WWTP
Sampling Frequency: Based on Dry Tons Land Applied
Sample Type: 38% VSR
Lab: CFPUA Lab
Sampling Point: Southside WWTP Storage Pad
Sampling Frequency: Annually
Sample Type: Grab
Lab: Summit Environmental Technologies, Inc

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State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
Division of Water Resources RESIDUALS SOURCE CERTIFICATION
INSTRUCTIONS FOR FORM: RSC 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 certification provides detailed information of residuals source generating facility and its residuals quality for land
application, distribution, or disposal in accordance with 15A NCAC 02T .1100. Do not submit this certification for review without
a corresponding application form (FORM: RLAP 11-15, FORM: DCAR 11-15, or FORM: SDR 11-15).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Residuals Source Certification (FORM: RSC 11-15):
® Submit the completed and appropriately executed Residuals Source Certification (FORM: RSC 11-15) 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 a separate certification for each source facility.
® For modified permits, submit a separate certification for only those facilities that are affected by the proposed modification.
® Complete the residuals source facility summary page. List all new, renewed, or modified facilities.
B. Residuals Source -Generating Facility Information:
® For each source facility, attach the following:
® Vicinity map - A vicinity map that shows the location of the facility and meets all of the criteria in the "_Map Guidance for
Residuals Land Application Permits".
® Process flow diagram and/or narrative - A detailed narrative and/or process flow diagram that describes how the residuals
are to be generated, treated, processed, and stored at the facility.
® Quantitative justification for residuals production rate - A quantitative justification for the value provided in Item I. S.
Ensure that the amount of residuals listed is the maximum amount expected to be generated by the facility for the life of
the permit. In addition, ensure that this amount is equivalent to that which is actually to be land applied, distributed,
and/or disposed, including any chemicals, amendments, or other additives that are added to the residuals during
processing.
® Sampling plan - A detailed sampling plan for the residuals source -generating facility. Ensure that the plan identifies
sampling points, sampling frequency, sample type, as well as the Division -certified laboratory to be used. In addition,
ensure that the plan details how the facility and/or the residuals are monitored for any applicable pathogen reduction and
vector attraction reduction requirements. Note that all sampling and monitoring must be completed on the residuals as
they are to be land applied, distributed, and/or disposed.
C. Residuals Quality Information:
® For each source facility, attach the following:
® Laboratory analytical reports and operational data - reports for all laboratory analyses used to complete this certification.
® Documentation that the facility complies and/or the residuals comply with any applicable pathogen reduction and vector
attraction reduction requirements.
® For new facility that may have not yet been constructed and analytical results of residuals cannot be obtained, please
attach analytical results of residuals generated from a similar facility along with the description of similarities of the two
facilities.
INSTRUCTIONS FOR FORM: RSC 06-16 Page 1 of 1

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State of North Carolina
nWR
Department of Environmental Quality
Division of Water Resources
Division of Water Resources RESIDUALS SOURCE CERTIFICATION
FORM: RSC 06-16
I. RESIDUALS SOURCE -GENERATING FACILITY INFORMATION (See Instruction B.):
1. Facility Name: Sweeny WTP
2. Facility permit holder is: Federal,] State, 0 Local Government, or [] Private.
Facility permit issued by: Div. of Water Resources,[ Div. of Environmental Health,
or 0,, Other (explain: ' "!).
3. Facility contact person and title: John Malone, Water Resources 1VIanaer
Complete mailing address: 235 Government Center Drive
City t Wilmin on State: NUa Zip: 28403!
Telephone number: 910 3324578 E-mail address: [e-mail]
4. Facility physical address: 1833 North 5th Avenue
City: IW i.ton, State: NC Zip:
Coordinates: Latitude: +34° il_5' 3 Longitude: 77 5644"
Datum: NAD 84 Level of accuracy: Kecond
Method of measurement:,
5. Purpose of the facility:
[] treatment of municipal wastewater,] treatment of 100% domestic wastewater,
treatment of potable water, C] treatment of 100% industrial wastewater,
0 treatment of industrial wastewater mixed with domestic wastewater,
(approximate percentages: % industrial and . % domestic)
0 other (explain: ).
6. Does the facility have an approved pretreatment program: II Yes No
7. Facility permitted/design flow: 35.0, MGD and facility average daily flow: 'i19.5 MGD
8. Average amount of residuals being generated at this facility 4.568 all sources combined dry tons per year.
9. Specify the following regarding treatment and storage volumes available at the facility:
Type and volume of residuals treatment: 2 Clarifiers and 2 Thickeners
Type and volume of residuals storage (i.e., outside of residuals treatment units): Pumped to Northside for dewatering and
stored at Southside WWTP for 30 da s
RESIDUALS QUALITY INFORMATION (See Instruction C.):
1. Specify if residuals are regulated under:
0 40 CFR Part503 or [ 40 CFR Part 257.
Note: Only residuals that are generated during domestic/municipal wastewater treatment processes are regulated under 40
CFR Part 503, otherwise, the residuals are regulated under 40 CFR Part 257.
2. Specify if residuals are defined under 15A NCAC 02T.1102(61 as:
N Biological ]]: Non -Biological
FORM: RSC 06-16 Page 1 of 5

Note: Biological residuals are residuals that have been generated during the treatment of domestic wastewater, animal
processing wastewater, or the biological treatment of industrial wastewater (biological treatment is a system that utilizes
biological processes including lagoons, activated sludge systems, extended aeration systems, and fixed film systems).
3. Hazardous Waste Determination: Complete the following to demonstrate that the residuals are non -hazardous under
RCRA: (Note - this item does not have to be completed for facilities that are less than 0.5 MGD in design flow that treat
100% non -municipal, domestic wastewater only)
a. Are the residuals listed in 40 CFR
§261.31-§261.33: ❑
yes no.
If yes, list the number(s):.':
b. Specify whether or not the residuals exhibit any of the characteristics defined by 40 CFR §261.21-
261.24: Q; yes 0 no.
Fill in the following tables with the results of the latest toxicity characteristic leaching procedure (TCLP) analysis as
well as those for corrosivity, ignitability, and reactivity:
Laboratory: Sheaf Env. Labs and Date of analysis: S 01M0
Passed corrosivity test: yes]
no. pH: s.u.
(2 < pH < 12.5)
Passed ignitability test: , yes
❑ no. Flashpoint: ?& OF (> 140°F)
Passed reactivity test: Oyes Ono. HCN: ND mg/kg (<250) & H2S: `60A mg/kg (<500)
TCLP Parameter
Limit Result
TCLP Parameter
Limit
Result
(mg/1) (mg/1)
(mg/1)
(mg/1)
Arsenic
5.0 ND
Hexachlorobenzene
0.13
ND
Barium
100.0 0.27
Hexachloro-1,3-Butadiene
0.5
ND
Benzene
0.5 ND
Hexachloroethane
3.0
ND
Cadmium
1.0 ND
Lead
5.0
ND
Carbon Tetrachloride
0.5 ND
Lindane
0.4
ND
Chlordane
0.03 ND
Mercury
0.2
ND
Chlorobenzene
100.0 ND
Methoxychlor
10.0
ND
Chloroform
6.0 ND
Methyl Ethyl Ketone
200.0
ND
Chromium
5.0 ND
Nitrobenzene
2.0
ND
m-Cresol
200.0 ND
Pentachlorophenol
100.0
ND
o-Cresol
200.0 ND
Pyridine
5.0
ND
p-Cresol
200.0 ND
Selenium
1.0
ND
Cresol
200.0 ND
Silver
5.0
ND
2,4-D
10.0 ND
Tetrachloroethylene
0.7
ND
1,4-Dichlorobenzene
7.5 ND
Toxaphene
0.5
ND
1,2-Dichloroethane
0.5 ND
Trichloroethylene
0.5
ND
1, 1 -Dichloroethylene
0.7 ND
2,4,5-Trichlorophenol
400.0
ND
2,4-Dinitrotoluene
0.13 ND
2,4,6-Trichlorophenol
2.0
ND
Endrin
0.02 ND
2,4,5-TP (Silvex)
1.0
ND
Heptachlor and its Hydroxide
0.008 ND
Vinyl Chloride
0.2
ND
FORM: RSC 06-16 Page 2 of 5

4. Metals Determination: Complete one of the following tables (i.e., as applicable) to demonstrate that the residuals do not
violate the ceiling concentrations for metals regulated under 15A NCAC 02T .1105.
a. For Distribution/Land Application: Fill in the following table with the results of the latest analyses (i.e., on a dry weight
basis) for the following metal parameters:
Laboratory: ka oint Anal 'cat and Date of analysis: 2/26/19
Parameter
Ceiling
Monthly Average
Result
Concentration Limits
Concentration Limits
(ClassA & ClassB)
(Class A Only)
(mg/kg)
(mg/kg)
(mgIkg)
Arsenic
75
41
6.96
Cadmium
85
39
<1.0
Copper
4,300
1,500
133
Lead
840
300
21.3
Mercury
57
17
0.189
Molybdenum
75
n/a
4.02
Nickel
420
420
21.8
Selenium
100
100
<5.0
370
Zinc
::::�7,500�2�,80O
b. For Surface WPOSal Unit ilandtillt: Fill in the following table with the results of the latest analyses (i.e., on a dry weight
basis) for the following metal parameters:
Laboratory: and Date of analysis: .
Distance from Disposal Arsenic Chromium Nickel
Unit to Boundary to
Closest Property Line
(meters, check one)
(mg/kg)
(mg/kg)
200
220
(mg/kg)
> 0 but < 25
30
210
Ej > 25 but < 50
34
240
> 50 but < 75
39
260
270
> 75 but < 100
46
300
320
[] >_ 100 but < 125
53
360
390
a > 125
62
450
420
Result (mg/kg)
FORM: RSC 06-16 Page 3 of 5

5. Nutrient/Micronutrient Determination: Complete the following:
a. Total solids: 17.4 %.
b. Fill in the following table with the results of the latest analyses (i.e., on a dry weight basis) for the following nutrient and
micronutrient parameters:
Laboratory: Waypoint Analytical and Date of analysis: 2/26/19
c. Using the results listed in Item II. 5b. above, calculate the sodium adsorption ration (SAR): 0.33
[Note: If residuals contain SAR of 10 or higher, the applicant shall obtain recommendations from the local Cooperative
Extension Office, the Department of Agriculture and Consumer Services, the Natural Resource Conservation Service, a
North Carolina Licensed Soil Scientist, or an agronomist, prior to land application of residuals. The recommendations shall
address the sodium application rate, soil amendments (e.g., gypsum, etc.), or a mechanism for maintaining site integrity
and conditions conducive to crop growth].
d. Specify the mineralization rate to be used in calculating the plant available nitrogen (PAN) of the residuals: 26 %. This
rate is a (check one): M, default value, or actually established.
If the residuals are not generated from the treatment of municipal or domestic wastewater, explain or provide technical
justification as to why the selected default value is appropriate to be applied to these residuals:
e. Calculate the PAN for the residuals (i.e., on a dry weight basis) and fill the results in the following table:
Application Method First (lsh Year PAN Five -Year
Maximum Adjusted PAN
(mg/kg) (mg1kP)
Surface 5,202 7,547
Injection/Incorporation 6,982 9,327
6. Other Pollutants Determination: Specify whether or not there are any other pollutants of concern in the residuals and provide
the results of the latest analyses: N/A
FORM: RSC 06-16 Page 4 of 5

7. Pathogen Reduction: Per 15A NCAC 02T.1106, specify how residuals will meet the pathogen reduction requirements:
a. For Distribution/Land Application of Class A or Equivalent.
A fecal coliform density that is demonstrated to be less than 1,000 MPN per gram of total dry solids,
or
❑ A salmonella sp. density that is demonstration to be less than 3 MPN per 4 grams of total dry solids.
AND one of the followings (except for non -biological residuals):
❑ Alternative 1 [15A NCAC 02T.1106(b)(3)(A)] - Time/Temperature Compliance.
Alternative 2 [15A NCAC 02T.1106(b)(3)(B)] - Alkaline Treatment.
❑ Alternative 3 [15A NCAC 02T.1106(b)(3)(C)] - Prior Testing for Enteric Virus/Viable Hehninth Ova.
Alternative 4 [15A NCAC 02T. 1 106(b)(3)(D)] - No Prior Testing for Enteric Virus/Viable Hehminth Ova.
❑ Alternative 5 [15A NCAC 02T.1106(b)(3)(E)-(K)] - Process to Further Reduce Pathogens (PFRP).
Specify one: composting, ❑ heat drying, Qi heat treatment,
❑ thermophilic aerobic digestion, Ll beta ray irradiation,
gamma ray irradiation,- or ❑ pasteurization.
b. For Land Application of Class B:
Alternative 1 [15A NCAC 02T.1106(c)(1)] - Fecal Coliform Density Demonstration.
❑ Alternative 2 [15A NCAC 02T. 1 106(c)(Z)J. - Process to Significantly Reduce Pathogens (PSRP).
Specify one: ❑ aerobic digestion, ❑ air drying,] anaerobic digestion,
composting, or ❑ time stabilization.
c. For Surface Disposal:
Select One of the Class A or Equivalent Pathogen Reduction Alternatives in Item 11. 7a. above.
Select One of the Class B or Equivalent Pathogen Reduction Alternatives in Item 11.7b. above.
[]. Exempt - If Daily Cover Alternative is chosen in Item 11.8. below [15A NCAC 02T.1106(a)(2)].
Not Applicable - Non -Biological Residuals with NO Domestic Wastewater Contribution.
8. Vector Attraction Reduction (VARY: Per 15A NCAC 02T.1107. specify how residuals will meet the VAR requirements:
❑; Alternative 1 [I5ANCAC 02T. I 107(a)(1)] - 38% Volatile Solids Reduction (Aerobic/Anaerobic Digestion).
Alternative 2 [15A NCAC 02T. 1107(a)(2)] - 40-Day Bench Scale Test (Anaerobic Digestion).
❑ Alternative 3 [15A NCAC 02T. I 107(a)(3)] - 30-Day Bench Scale Test (Aerobic Digestion).
Alternative 4 [15A NCAC 02T. 1 107(a)(4)] - Specific Oxygen Uptake Rate Test (Aerobic Digestion).
Alternative 5 [15A NCAC 02T. 1 107(a)(5)] - 14-Day Aerobic Processes.
Alternative 6 [15A NCAC 02T.I 107(a)(6)] - Alkaline Stabilization.
❑ Alternative 7 [15A NCAC 02T.I 107(a)(7)] - Drying of Stabilized Residuals.
❑, Alternative 8 [15A NCAC 02T.I 107(a)(8)] - Drying of Unstabilized Residuals.
E] Alternative 9 [15A NCAC 02T.I 107(a)(9)] - Injection.
Alternative 10 [15A NCAC 02T. I 107(a)(1 0)] - Incorporation.
], Alternative for Surface Disposal Units Only - Soil/Other Material Cover [15A NCAC 02T. 1 107(b)(2)].
Not Applicable - Non -Biological Residuals with NO Domestic Wastewater Contribution.
Note: For animal processing residuals, only alternatives 9 or 10 may be chosen due to the nuisance conditions that typically
occur when these residuals are applied and left on the land surface.
FORM: RSC 06-16 Page 5 of 5

VICINITY MAP �"1(NAGR�
('' e k
.yea 1,1101,10 �
- � t
Wilmington
Water Treatment "�►
Sih Ave
e�
Cape Fear Regional c f
Community —
COUNTY: New Hanover OWNER(S): CFPUA - Sweeny WTP

Residuals Sampling Plan
Cape Fear Public Utility Authority Land Application Program
Sweeney Water Treatment Plant
Nutrients and Metals Anal sis
Sampling Point: Southside WWTP Storage Pad
Sampling Frequency: Based on Dry Tons Land Applied
Sample Type: Grab
Lab: Waypoint Analytical Virginia, Inc.
Pathogen
Vector
TCLP
Sampling Point: Sweeney WTP
Sampling Frequency: N/A
Sample Type: N/A
Lab: N/A
Sampling Point: Sweeney WTP
Sampling Frequency: N/A
Sample Type: N/A
Lab: N/A
Sampling Point: Southside WWTP Storage Pad
Sampling Frequency: Annually
Sample Type: Grab
Lab: Summit Environmental Technologies, Inc

ON

Residuals Sampling Plan
Cape Fear Public Utility Authority Land Application Program
Northside/ Southside Wastewater Treatment Plants
Nutrients and Metals Analvsis
Sampling Point: Southside WWTP Storage Pad
Sampling Frequency: Based on Dry Tons Land Applied
Sample Type: Grab
Lab: Waypoint Analytical Virginia, Inc.
Pathogen
Vector
TCLP
Sampling Point: Southside and Northside WWTP
Sampling Frequency: Based on Dry Tons Land Applied
Sample Type: Time and Temperature
Lab: CFPUA Lab
Sampling Point: Southside and Northside WWTP
Sampling Frequency: Based on Dry Tons Land Applied
Sample Type: 38% VSR
Lab: CFPUA Lab
Sampling Point: Southside WWTP Storage Pad
Sampling Frequency: Annually
Sample Type: Grab
Lab: Summit Environmental Technologies, Inc

SHEALY ENVIRONMENTAL SERVICES, INC.
Report of Analysis
Synagro
12701 Lancaster Hwy
Pineville, NC 28134
Attention: Melvin Goad
Project Name: Cape Fear
Lot Number:UD30007
Date Completed:05/14/2019
05/15/2019 9:06 AM
Approved and released by7
Lab Director - Greenville: Lucas Odom
MOE
The electronic signature above is the equivalent of a handwritten signature.
This report shall not be reproduced, except in its entirety, without the written approval of Shealy Environmental Services, Inc.
Shealy Environmental Services, Inc.
106 Vantage Point Drive West Columbia, SC 29172 [phone] Fax [phone] www.shealylab.com
Page 1 of 9

SHEALY ENVIRONMENTAL SERVICES, INC.
SC DHEC No: 32010001 NELAC No: E87653 NC DENR No: 329 NC Field Parameters No: 5639
Case Narrative
Synagro
Lot Number: UD30007
This Report of Analysis contains the analytical result(s) for the sample(s) listed on the Sample Summary
following this Case Narrative. The sample receiving date is documented in the header information
associated with each sample.
All results listed in this report relate only to the samples that are contained within this report.
Sample receipt, sample analysis, and data review have been performed in accordance with the most
current approved NELAC standards, the Shealy Environmental Services, Inc. ("Shealy") Quality
Assurance Management Plan (QAMP), standard operating procedures (SOPS), and Shealy policies. Any
exceptions to the NELAC standards, the QAMP, SOPS or policies are qualified on the results page or
discussed below.
Where applicable, all soil sample analysis are reported on a dry weight basis unless flagged with a "W"
qualifier
If you have any questions regarding this report please contact the Shealy Project Manager listed on the
cover page.
The pH analysis associated with the sample(s) in this report was/were performed after the method
recommended 15 minute holding time.
Flashpoint
Due to an instrument malfunction, the flashpoint analysis had to be subcontracted to Eurofins Test
America. This data is found on a separate subcontracted report.
Shealy Environmental Services, Inc.
106 Vantage Point Drive West Columbia, SC 29172 [phone] Fax [phone] www.shealylab.com
Page 2 of 9

SHEALY ENVIRONMENTAL SERVICES, INC.
Sample Summary
Synagro
Lot Number: UD30007
Sample Number Sample ID Matrix Date Sampled Date Received
001 Cape Fear Solid 04/29/2019 1000 04/30/2019
(1 sample)
Shealy Environmental Services, Inc.
106 Vantage Point Drive West Columbia, SC 29172 [phone] Fax [phone] www.shealylab.com
Page 3 of 9

Client:Synagro Laboratory I D: U D30007-001
Description: Cape Fear Matrix: Solid
Date Sampled:04/2912019 1000 % Solids: 29.6 0510112019 0118
Date Received:0413012019
Inorganic non-metals
Run Prep Method
Analytical Method
Dilution Analysis Date Analyst
Prep Date Batch
1
(Paint Filter) 9095E
1
04/3012019 2238 HET
.
1
(pH) 9045D
1
04/3012019 2311 HET
15226
1
(Reactive Cya) 7.3.3
1
05/01/2019 1641 MSG
04/30/2019 1020
1
(Reactive Sul) 7.3.4
1
04/30/2019 2009 HET
04/30/2019 1020
CAS Analytical
Parameter
Number Method
Result Q LOQ
Units
Run
Paint Filter Test
9095B
Pass
pass/fail
1
pH @ 22.3 ° C
9045D
7.0
su
1
Reactive Cyanide
7.3.3
ND 50
mglkg
1
Reactive Sulfide
7.3.4
60 50
mglkg
1
Run Prep Method
1 131115030B
Parameter
Benzene
2-Butanone (MEK)
Carbon tetrachloride
Chlorobenzene
Chloroform
1,2-Dichloroethane
1,1-Dichloroethene
etrachloroethene
Trichloroethene
Vinyl chloride
Surrogate
1,2-Dichloroethane-d4
Bromofluorobenzene
Toluene-d8
Run Prep Method
1 131113520C
TCLP Volatiles
Analytical Method Dilution Analysis Data Analyst Prep Date Batch Leachate Date
8260E 10 05/12/2019 2040 KGT 16427 05/10/2019 0139
CAS Analytical
Number Method
71-43-2
8260B
78-93-3
8260B
56-23-5
8260B
108-90-7
8260E
67-66-3
8260B
107-06-2
8260B
75-35-4
8260B
127-18-4
8260E
79-01-6
8260B
75-01-4
8260B
Run 1 Acceptance
Q % Recovery Limits
100 70-130
103 70-130
108 70-130
Result Q
LOQ
Units
Run
ND
0.050
mg/L
1
ND
0.10
mg/L
1
ND
0.050
mg/L
1
ND
0.050
mg/L
1
ND
0.050
mg/L
1
ND
0.050
mg/L
1
ND
0.050
mg/L
1
ND
0.050
mg/L
1
ND
0.050
mg/L
1
ND
0.010
mg/L
1
TCLP Semivolatiles
Analytical Method Dilution Analysis Date Analyst Prep Date Batch Leachate Date
8270D 1 05/13/2019 1110 JCG 05/03/2019 1723 15624 05/02/2019 2315
Parameter
CAS
Number
Analytical
Method
Result Q
LOQ
Units
Run
1,4-Di
106-46-7
8270D
NO
0.040
mg/L
1
2,4-Dinitrotoluene
121-14-2
8270D
ND
0.080
mg/L
1
Hexachlorobenzene
118-74-1
8270D
ND
0.040
mg/L
1
Hexachlorobutadiene
87-68-3
8270D
ND
0.040
mg/L
1
LOQ = Limit of Quantitation B = Detected in the method blank E = Quahtitation of compound exceeded the calibration range
ND = Not detected at or above the LOQ N = Recovery is out of criteria P = The RPD between two GC columns exceeds 40%
H = Out of holding time W = Reported on wet weight basis
healy Environmental Services, Inc.
106 Vantage Point Drive West Columbia, SC 29172 [phone] Fax [phone] www.shealylab.com
Page 4 of 9

Client:Synagro
Description: Cape Fear
Date Sampled:04/29/2019 1000
Date Received: 0413012019
Run Prep Method
1 131113520C
Parameter
Hexachloroethane
2-Methylphenol
3+4-Methylphenol
Nitrobenzene
Pentachlorophenol
Pyridine
2,4, 5-Trichlorophenol
2,4,6-Trichlorophenol
Surrogate
2-Fluorobiphenyl
2-Fluorophenol
Nitrobenzene-d5
Phenol-d5
Terphenyl-d14
2,4,6-Tribrom ophen of
Run Prep Method
1 131118151A
Parameter
2,4-D
2,4,5-TP (Silvex)
Surrogate
DCAA
Run Prep Method
1 1311 /3520C
Parameter
gamma-BHC (Lindane)
Chlordane
Endrin
Heptachlor
Heptachlor epoxide
Laboratory ID: U D30007-001
Matrix: Solid
% Solids: 29.6 06/01/2019 0118
TCLP Semivolatiles
Analytical Method Dilution Analysis Date Analyst Prep Date Batch Leachate Date
8270D 1 05/13/2019 1110 JCG 05/03/2019 1723 15624 05/0212019 2315
CAS Analytical
Number Method
67-72-1
95-48-7
106-44-5
98-95-3
87-86-5
110-86-1
95-95-4
88-06-2
Run
1 Acceptance
Q % Recovery Limits
62
37-129
41
24-127
85
38-127
54
28-128
86
10-148
53
41-144
8270D
8270D
8270D
8270D
8270D
8270D
8270D
Result Q
LOQ
Units
ND
0.040
mg/L
ND
0.040
mg/L
ND
0.040
mg/L
ND
0.040
mg/L
ND
0.20
mg/L
ND
0.040
mg/L
ND
0.040
mg/L
ND
0.040
mg/L
TCLP Herbicides
Analytical Method Dilution Analysis Date Analyst Prep Date Batch Leachate Date
8151A 1 05/08/2019 1859 DAL1 05/07/2019 1815 15932 05/02/2019 2315
Run
1
1
1
1
1
1
1
CAS Analytical
Number Method Result Q LOQ Units Run
94-75-7 8151A ND 0.020 mg/L 1
93-72-1 8151A ND 0.0050 mg/L 1
Run 1 Acceptance
Q % Recovery Limits
69 50-112
TCLP Pesticides
Analytical Method Dilution Analysis Date Analyst Prep Date Batch Leachate Date
8081 B 1 05/08/2019 1710 CHG 05/03/2019 1723 15625 05/0212019 2315
CAS
Number
Analytical
Method
Result Q
LOQ
Units
Run
58-89-9
8081B
ND
0.00040
mg/L
1
57-74-9
8081 B
ND
0.0040
mg/L
1
72-20-8
8081 B
ND
0.00040
mg/L
1
76-44-8
8081B
ND
0.00040
mg/L
1
1024-57-3
8081B
ND
0.00040
mg/L
1
LOQ = Limit of Quantitation B = Detected in the method blank E = Quantitation of compound exceeded the calibration range
ND = Not detected at or above the LOQ N = Recovery is out of criteria P = The RPD between two GC columns exceeds 40%
9 = Out of holding Gme W = Reported on wet weight basis
iealy Environmental Services, Inc,
106 Vantage Point Drive West Columbia, SC 29172 [phone] Fax [phone] www.shealylab.eom
Page 5 of 9

Client:Synagro
Description: Cape Fear
Date Sampled:04/29/2019 1000
Date Received:04130/2019
TCLP Pesticides
Run Prep Method Analytical Method Dilution Analysis Date Analyst
1 1311/3520C 8081E 1 05/08/20191710 CHG
Laboratory ID:UD30007-001
Matrix: Solid
% Solids: 29.6 05101/2019 0118
Prep Date Batch Leachate Date
05/03/2019 1723 15625 05/02/2019 2315
CAS Analytical
Parameter Number Method Result Q LOCI Units Run
Methoxychlor 72-43-5 8081B ND 0.0016 mg/L 1
Toxaphene 8001-35-2 8081E ND 0.0080 mg/L 1
Run 1 Acceptance
Surrogate Q % Recovery Limits
Decachlorobiphenyl 60 20-131
Tetrachloro-m-xylene 62 26-132
TCLP Metals
Run Prep Method
1 1311/3010A
1 131117470A
Analytical Method Dilution Analysis Date Analyst
6010D 1 05/09/2019 0238 JCF
7470A 1 05/06/2019 2057 JMH
Prep Date Batch Leachate Date
05/0612019 1747 15803 05/02/2019 2315
05/05/2019 1242 15705 05/02/2019 2315
CAS Analytical
Parameter
Number Method
Result Q
LOQ
Units
Run
Arsenic
7440-38-2 6010D
ND
0.15
mg/L
1
Barium
7440-39-3 6010D
0.27
0.25
mg/L
1
Cadmium
7440-43-9 6010D
ND
0.050
mg/L
1
Chromium
7440-47-3 6010D
ND
0.10
mg/L
1
Lead
7439-92-1 601OD
ND
0.10
mg/L
1
Mercury
7439-97-6 7470A
ND
0.0020
mg/L
1
Selenium
7782-49-2 6010D
ND
0.20
mg/L
1
Silver
7440-22-4 6010D
ND
0.10
mg/L
1
LOQ = Limit of Quentitation B = Detected in the method blank E = Quantitation of compound exceeded the calibration range
ND = Not detected at or above the LOQ N = Recovery is out of criteria P = The RPD between two GC columns exceeds 40%
H = Out of holding time W = Reported on wet weight basis
Shealy Environmental Services, Inc.
106 vantage Point Drive West Columbia, SC 29172 [phone] Fax [phone] www.shealylab.com
Page 6 of 9

Chain of Custody
and
Miscellaneous Documents
Shealy Environmental Services, Inc.
106 Vantage Point Drive West Columbia, SC 29172 [phone] Fax [phone] www.shealylab.com
Page 7 of 9

SHEALY ENVIRONMENTAL SERVICES INC.
E
z
xIt
d
Shealy Environmental Services, Inc.
106 Vantage Point Drive West Columbia, SC 29172 [phone] Fax [phone] www.shealylab.com
Page 8 of 9

SHEALY ENVIRONMENTAL SERVICES, INC.
Shw,tj FmironveMoi Sevier=, W.. ftp I of l
Ilrrumrrtttumltc, 4itiflll:S;-14 t'R�11� [Sates. L.2.`7lIiS
��m�Ie Receipt Checklist (SRC)
Glilont: Syetagt+a Cooler inspected byMatw rsll I 0 #+3Qn9 t tit ; �I >p007
Means afreocipt. `5F13l Clitltt 0 UPS 3 FedEx
Ej Other:
❑ 'Yesi
WIND
1.. lVere custody seats present on the cwlcr*
Q Yes Nn Nit 2. tf eustod�r scats QrQ +AM4 were' thz-v intact rtltd ettllx eft?
p-H Strip TD: NA Chlorine w Strip 113: NA 'Tested by.- NA
original remperature.y upon rweipt ! Derived (C•orrem d) tomper-Mare Upon rouipt "WiDEiit Snatls-Ctl ft ID.- ill-6I1
tl 3.0 ;a-oC ML jhA „C NA /NA aC W,4 ;NA cC
Mettiod; C ctsuperatas; $Iwnh ( je alnst Brittle IR Gu t lD: IR awl Correotiou l±actoc �C
Method of coolant: 0 Wst Ice ® loe Pack$ © ice ❑ _ NQtte _
Y Q No OI, A J. Ifnemperature of any cooler exceed 6.01C, �> as Project NUnager Notified?
l I PM was Notified by. phone f email f face-to•facc (circle one).
Yes
[i No
d NA14.
is. tl't-- wnimerciol couriers packitig all p attached to this f'orrtt?
® VW
ONO
5_ Were proper otlsrody praaedurea (relingtdshed!'received) followed?
0 �
❑ No
6, wetre satople, IDS Ilsted on die COC?
® Yeesl
❑ No
7. 'Were emimple IAs fisted on all sample cantainet`s?
0 Yes
❑ Nc
8. Wa3 (Alectiva ditto & tulle listed oil 610 COC?
❑ Yes
21 No
?. Was collection elate & time listed on ad sample conta-rtlem?
® Yes
© No
10. Did all container 1allel informatinn (if); date, time) agree with the COC?
® Yes
Q No
11. Were tests to be �wiforitted tinted on the COC? -- --
® Yr_s
❑tau
12. Did all sampics Srrivc in the proper ootttaiysns for each test andlor 41 SOW condition
(unbrokcn, lids on, cte.)7 -
�j Yon
0 No
13- %%,as sadequsate sample volurne avatbable?
es
ONO
14. `4irs re all samples reach [ withiti % the holding time or 48 hours, whichc1mr coma first?'
Ye4
®No
1S. Were any samples container missirtvr cem (circle vie) -Sampjes Nor listed ors. COM,
For N A and KSK-175 samples, were bubbles present --pea-size" (!i+'or 6min in diautieter)
III WW of the VOA vials?
rlyI&
im
17. Were all T3T{O.tmetaINInutrienisamples reL6yt:d at a pN of<29
18. Wort all cyan ido samp Its mocived at a H> 12 and sulfide satn tes received. at a h;7- 9?
® Yes
❑ No
f;Zl NA
19. were all upp W451c NHs+TKNik anitWphonoU625 t = 9.5mgQ stunples frco of icsidual
Eh toratte?
Q Y` `
N0
NA121.
20. Were client m'narkslrequests (i e. requested dilutions, MSJ[ WD desipnflEion. , etc--- F
corm cdy transcribed front the COC into the comment section in LINT s?
Yes bin Was the quote number listed on the container label? Ti"Yee, Quotc Ir MA
Sample Preservation (Must be completed r'or any satnple(4) ittcom-dly pmservtad or with Im adspacc
amplc(s) NA - .--- were reDeived'inemectly preserved and were Wjuslud wxordingly
sample rcevivillg with NA mL of circle one;1 ik4, FTN05, HCt, MOH OH using SR k NA
Iainw oEprescrvation MA _ _ . 117mom than one prescr►ative is n�xied, please note in the comment-t holaw.
--
'arnple(s) ItiEA wcrc reccIved with bubble& >6 ittnt in €1<iania er.
ampics(s) NA Ftiere mceivedtwith TRC> U S Rigel. (Tr*19 is im) and were
ju iLM arcs}rd-mgly in swnptc rc=iving with sodium thiosulfate (NkS.Oa) Fvith Shealy 211; NA
SR. harcode lalacls Applied by. ISH Bate: 04/30,119
Comments:
Shealy Environmental Services, Inc.
106 Vantage Point Drive West Columbia, SC 29172 (803) 791-97oo Fax [phone] www.shealylab.com
Page 9 of 9

eurofins
Environment Vesting
TestAmerica
Eurofins TestAmerica, Nashville
2960 Foster Creighton Drive
Nashville, TN 37204
Tel: [phone]
Laboratory Job ID-. 490-173159-1
Client Project/Site: UD3007
For:
Shealy Environmental Services, Inc.
106 Vantage Point Drive
West Columbia, South Carolina 29172
Attn: Ms. Kelly M Nance
Authorized for release by:
51912019 1:01:34 PM
Quinita Reynolds, Manager of Project Management Assistants
[phone]
[e-mail]
Designee for
Ken Hayes, Project Manager II
[phone]
[e-mail]
The test results in this report meet all 2003 NELAC and 2009 TN/ requirements for accredited
parameters, exceptions are noted in this report. This report may not be reproduced except in full,
and with written approval from the laboratory. For questions please contact the Project Manager
at the e-mail "address or telephone number listed on this page.
This report has been electronically signed and authorized by the signatory. Electronic signature is
intended to be the legally binding equivalent of a traditionally handwritten signature.
J1
Results relate only to the items tested and the sample(s) as received by the laboratory.

Client: Shealy Environmental Services, Inc.
Project/Site: UD3007
Laboratory Job ID: 490-173159-1
Table of Contents
Cover Page..... ......................................... 1
Table of Contents ......................................... 2
Sample Summary ......................................... 3
Case Narrative ...........................................
4
Definitions ...............................................
5
Client Sample Results ......................................
6
QC Sample Results ............. ......................
. . 7
QC Association ...........................................
8
Chronicle................................................
9
Method Summary .......... . ...........................
10
Certification Summary ......... ............................
11
Chain of Custody .......................................
12
u
Page 2 of 13
Eurofins TestAmerica, Nashville
5/9/2019

Client: Shealy Environmental Services, Inc.
Project/Site: UD3007
Lab Sample ID Client Sample ID
490-173159-1 Cape Fear
Sample Summary
Matrix
Solid
Job ID: 490-173159-1
Collected Received �=
04/29/19 10:00 05/02/19 09:30
I
Page 3 of 13
Eurofins TestAmerica, Nashville
5/9/2019

Case Narrative
Client: Shealy Environmental Services, Inc. Job ID: 490-173159-1
Project/Site: UD3007
Job ID: 490-173159-1
Laboratory: Eurofins TestAmerica, Nashville
Job Narrative
490-173159-1
Comments
No additional comments.
Receipt
The sample was received on 5/2/2019 9:30 AM; the sample arrived in good condition, properly preserved and, where required, on ice. The
temperature of the cooler at receipt was 1.1 ° C.
General Chemistry
Method 1010A is applicable only to liquid matrix. This method has been modified to incorporate soil/solid matrices of the following
sample: Cape Fear (490-173159-1).
No additional analytical or quality issues were noted, other than those described above or in the Definitions/Glossary page.
Eurofins TestAmerica, Nashville
Page 4 of 13 5/9/2019

Definitions/Glossary
Client: Shealy Environmental Services, Inc. Job ID: 490-173159-1
Project/Site: UD3007
Aossary
Abbreviation These commonly used abbreviations may or may not be present in this report.
g Listed under the "D" column to designate that the result is reported on a dry weight basis
%R Percent Recovery
CFL Contains Free Liquid
CNF Contains No Free Liquid
DER Duplicate Error Ratio (normalized absolute difference)
Dil Fac Dilution Factor
DL Detection Limit (DoD/DOE)
DL, RA, RE, IN Indicates a Dilution, Re -analysis, Re -extraction, or additional Initial metals/anion analysis of the sample
DLC Decision Level Concentration (Radiochemistry)
EDL Estimated Detection Limit (Dioxin)
LOD Limit of Detection (DoD/DOE)
LOQ Limit of Quantitation (DoD/DOE)
MDA Minimum Detectable Activity (Radiochemistry)
MDC Minimum Detectable Concentration (Radiochemistry)
MDL Method Detection Limit
ML Minimum Level (Dioxin)
NC Not Calculated
ND Not Detected at the reporting limit (or MDL or EDL if shown)
PQL Practical Quantitation Limit
QC Quality Control
RER Relative Error Ratio (Radiochemistry)
RL Reporting Limit or Requested Limit (Radiochemistry)
RPD Relative Percent Difference, a measure of the relative difference between two points
TEF Toxicity Equivalent Factor (Dioxin)
TEQ Toxicity Equivalent Quotient (Dioxin)
Eurofins TestAmerica, Nashville
Page 5 of 13 5/9/2019

Client: Shealy Environmental Services, Inc.
Project/Site: UD3007
Aient Sample ID: Cape Fear
Date Collected: 04/29/19 10:00
General Chemistry
Anelyte
Flashpoint
Client Sample Results
Job ID: 490-173159-1
Lab Sample ID: 490-173159-1
Matrix: Solid
Result Qualifier
RL
RL Unit
D Prepared Analyzed
Dil Fac
3200
1.00 i
Degrees F
05/08/19 20:36
i
Eurofins TestAmerica, Nashville
5/9/2019
Page 6 of 13

QC Sample Results
Client: Shealy Environmental Services, Inc.
Project/Site: UD3007
Job ID: 490-173159-1
Aethod: 1010A - Ignitability, Pensky-Martens Closed -Cup Method
LLab Sample ID: MB 490-59363711
Client Sample ID: Method Blank
Matrix: Solid
Prep Type: Total/NA
Analysis Batch: 693637
MB MB
Analyte Result Qualifier
RL RL Unit D
Prepared Analyzed Dil Fac -` -
Flashpoint >200
1.00 Degrees F
05/08/19 20:35 1
Lab Sample ID: LCS 490-69363712
Client
Sample ID: Lab Control Sample
Matrix: Solid
Prep Type: Total/NA
Analysis Batch: 693637
Spike
LCS LCS
%Rec.
Analyte
Added
Result Qualifier Unit
D %Rec Limits
Flashpoint
81.0
77.30 Degrees F
95 94_ 106
Lab Sample ID: LCSD 490-693637/14
Client Sample ID: Lab Control Sample Dup
Matrix: Solid
Prep Type: Total/NA
Analysis Batch: 593637
Spike
LCSD LCSD
%Rec. RPD
Analyte
Added
Result Qualifier Unit
D %Rec Limits RPD Limit
Flashpoint
81.0
81.30 Degrees F
100 94 -106 5 20
Lab Sample ID: 490-173171-A-1 DU
Client Sample ID: Duplicate
Matrix: Solid
Prep Type: Total/NA
Analysis Batch: 593637
Sample Sample
DU DU
RPD
Analyte Result Qualifier
Result Qualifier Unit
D RPD Limit
LFlashpoint 54.3
59.50 Degrees F
9 10
Eurofins TestAmerica, Nashville
Page 7 of 13 5/9/2019

QC Association Summary
Client: Shealy Environmental Services, Inc.
Project/Site: UD3007
general Chemistry
Analysis Batch: 593637
Lab Sample ID
Client Sample ID
490-173159-1
Cape Fear
MB 490-593637/1
Method Blank
LCS 490-593637/2
Lab Control Sample
490-593637/14
Lab Control Sample Du
LLCSD
490-173171-A-1 DU
Duplicate
Job ID: 490-173159-1
Prep Type
Matrix
Method Prep Batch
Total/NA
Solid
1010A
Total/NA
Solid
1010A
Total/NA
Solid
1010A
Total/NA
Solid
1010A
Total/NA
Solid
1010A
a
Page 8 of 13
Eurofins TestAmerica, Nashville
5/9/2019

Lab Chronicle
Client: Shealy Environmental Services, Inc. Job ID: 490-173159-1
Project/Site: UD3007
Aient Sample ID: Cape Fear Lab Sample ID: 490-173159-1
Date Collected: 04/29/19 10:00 Matrix: Solid
Date Received: 05/02/19 09:30
Batch Batch Dil Initial Final Batch Prepared
Prep Type Type Method Run Factor Amount Amount Number or Analyzed Analyst Lab
Total/NA Analysis 1010A 1 593637 05/08/19 20:36 VRP TAL NSH - "
Laboratory References:
TAL NSH = Eurofins TestAmerica, Nashville, 2960 Foster Creighton Drive, Nashville, TN 37204, TEL [phone]
a
Eurofins TestAmerica, Nashville
Page 9 of 13 5/9/2019

Method Summary
Client: Shealy Environmental Services, Inc. Job ID: 490-173159-1
Project/Site: UD3007
Method Method Description Protocol Laboratory
1010A Ignitability, Pensky-Martens Closed -Cup Method SW846 TAL NSH
Protocol References:
SW846 ='Test Methods For Evaluating Solid Waste, Physical/Chemical Methods", Third Edition, November 1986 And Its Updates.
Laboratory References:
TAL NSW = Eurofins TestAmerica, Nashville, 2960 Foster Creighton Drive, Nashville, TN 37204, TEL [phone]
111
Eurofins TestAmerica, Nashville
Page 10 of 13 5/9/2019

N
Accreditation/Certification Summary
Client: Shealy Environmental Services, Inc.
Project/Site: UD3007
Job ID: 490-173159-1
_aboratory: Eurofins TestAmerica, Nashville
Unless otherwise noted, all analytes for this laboratory were covered under each accreditation/certification below.
Authority Program EPA Region Identification Number Expiration Date
North Carolina (VWIHSW) State Program 4 387 12-31-19
The following analytes are included in this report, but the laboratory is not certified by the governing authority. This list may include analytes for which
the agency does not offer certification.
Analysis Method Prep Method Matrix Analyte
South Carolina State Program 4 84009 [phone]
The following analytes are included in this report, but the laboratory is not certified by the governing authority. This list may include analytes for which
the agency does not offer certification.
Analysis Method Prep Method Matrix Analyte
* Accreditation/Certification renewal pending - accreditation/certification considered valid.
Eurofins TestAmerica, Nashville
Page 11 of 13
5/9/2019

TestAmedca
THE LEADER IN ENVIRONMENTAL TESTING 490-173159 Chain of Custody
Nashville, TN COOLER RECEIPT FORM
Cooler Received/Opened On 51212019 0930
t r
Time Samples Removed From Cooler_ _ + Time Samples Placed In Storage _ 3`t_ (2 }lour Window)
1. Tracking # 22_ (last 4 digits, FedExx)) f1 Courier: FedEx
IR Gun ID 17950357 pH Strip Lot %Chlorine Strip Lot
I
2. Temperature of rep. sample or temp blank when opened" i Degrees Celsius
3. If Item #2 temperature is 0°C or less, was the representative sample or temp blank frozen? YES NO..PI
4. Were custody seals on outside of cooler? ..NO ... NA
If yes, how many and where: (ter 1�1_ _ _
S. Were the seals intact, signed, and dated correctly? E ...NO...NA
6. Were custody papers inside cooler? ...NO...NA
I certify.that I opened the cooler and answered 1uestions 1-6-11ntial) �.
7. Were custody seals on containers: YES C� and Intact YES ... NO.d!
Were these signed and dated correctly? YES...NO.&
8. Packing mat'l used? ubbte Plastic bag Peanuts Vermiculite Foam Insert Paper Other None
9. Cooling process: Ic Ice -pack Ice (direct contact) Dry ice Other None
10. Did all containers arrive in good condition (unbroken)? On ... NO ... NA
11. Were all container labels complete (#, date, signed, pres., etc)? &... NO ... NA
12. Did all container labels and tags agree with custody papers? 6�..NO... NA
13a. Were VOA vials received? YES.(1�2,.NA
b. Was there any observable headspace present in any VOA vial? YES ... NO..#dA)
19 On Larger than this.
14. Was there a Trip Blank In this cooler? YES.�t� , #IA If multiple coolers, sequence
I certify that I the cooler and answered c uestionnsss 7-14 ±intial} L
—
_ -unloaded 4-
15a. On pres'd bottles, did pH test strips suggest preservation reached the correct pH level?
YES ...NO ... tO
b. Did the bottle labels indicate that the correct preservatives were used
E65.. NO ... NA
16. Was residual chlorine present?
YES...NO..d
I certify that i checked for chlorine and off as per SOP and answered_ questions 15.16 iintiall
17. Were custody papers properly filled out (ink, signed, etc)?
4.—.
NO...NA
18. Did you sign the custody papers in the appropriate place?
YC..NO... NA
19. Were correct containers used for the analysis requested?
E1�S ..NO...NA
20. Was sufficient amount of sample sent in each container?
Y ..NO...NA
21. Were there Non -Conformance issues at login? YES_00 Was a NCM generated? YES. ..#
0
BIS = Broken in shipment
Cooler Receipt Forrn.doc LF-1 Revised 9.1317
End of Form
Page 12 of 13
5/9/2019 j

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5/9/2019 ;
I

Waypointo
ANALYTICAL
2/28/2019
Synagro-ADM
Jeff Spencer
1730 East Moore Street SE
SouthPort, NC, 28461
Ref: Analytical Testing
Report Number: 19-051-0203
Project Description: Cape Fear Mix
7621 Whitepine Road, Richmond, VA 23237
Main 804-743-9401 ° Fax [phone]
www.waypointanaiytical.com
Dear Jeff Spencer:
Waypoint Analytical Virginia, Inc. received sample(s) on 2/20/2019 for the analyses presented in the following
report.
The above referenced project has been analyzed per your instructions. The analyses were performed in
accordance with the applicable analytical method. Sub -contracted testing is noted on the Sample Summary Table
if applicable.
The analytical data has been validated using standard quality control measures performed as required by the
analytical method. Quality Assurance, method validations, instrumentation maintenance and calibration for all
parameters (NELAP and non-NELAP) were performed in accordance with guidelines established by the USEPA
(including 40 CFR 136 Method Update Rule May 2012) and NELAC unless otherwise indicated.
Certain parameters (chlorine, pH, dissolved oxygen, sulfite...) are required to be analyzed within 15 minutes of
sampling. Usually, but not always, any field parameter analyzed at the laboratory is outside of this holding time.
Refer to sample analysis time for confirmation of holding time compliance.
The results are shown on the attached Report of Analysis(s). Results for solid matrices are reported on an as -
received basis unless otherwise indicated. This report shall not be reproduced except in full and relates only to
the samples included in this report.
Please do not hesitate to contact me or client services if you have any questions or need additional information.
Sincerely,
&'U to oar
Pauric McGroary
Agronomist
Laboratory's liability in any claim relating to analyses performed shall be limited to, at laboratory's option, repeating the
analysis in question at laboratory's expense, or the refund of the charges paid for performance of said analysis.
Arizona AZ0629 New Jersey VA011 Pennsylvania 68-03109 Virginia 460014
Florida E871087 North Carolina 257 South Carolina 93007
s
Page 1 of 6

� 4V -V PT
- _
-ANALnt'
YTICAL
7621 Whitepine Road, Richmond, VA 23237
Main 804-743-9401 ° Fax [phone]
www.waypointanalytical.com
Sample Summary Table
Report Number:
19-051-0203
Client Project Description:
Cape Fear Mix
Lab No
Client Sample ID
Matrix
64866
Cape Fear Mix
Solids
64866
Cape Fear Mix
Solids
64866
Cape Fear Mix
Solids
64866
Cape Fear Mix
Solids
64866
Cape Fear Mix
Solids
64866
Cape Fear Mix
Solids
64866
Cape Fear Mix
Solids
64866
Cape Fear Mix
Solids
Date Collected
Date Received
Method
Lab ID
02/19/2019
13:00
02/20/2019
02/19/2019
13:00
02/20/2019
SM-4500-NH3C
WTN
02/19/2019
13:00
02/20/2019
9045D
WTN
02/19/2019
13:00
02/20/2019
4500NO3F-2011
WTN
02/19/2019
13:00
02/20/2019
6010D
WTN
02/19/2019
13:00
02/20/2019
SW-7471B
WTN
02/19/2019
13:00
02/20/2019
SM-4500-NH3C-TKN
WTN
02/19/2019
13:00
02/20/2019
SM-2540G
WTN
WTN: Waypoint Analytical - TN, Memphis, TN, Certification: #1354
Paae 2 of 6

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Waypoi nt
ANALYTICAL
Customer Number: 45637
Customer Name: Synagro-ADM
Report Number: 19-051-0203
O Fed Ex O US Postal
40 UPS 0 Client
7621 Whitepine Road, Richmond, VA 23237
Main 804-743-9401 ° Fax [phone]
www.waypoi nta nalytical.com
Cooler Receipt Form
Shipping Method
O Lab O Other
0 Courier Thermometer ID:
Shipping container/cooler uncompromised? 0 Yes
Number of coolers received
0 No
Custody seals intact on shipping container/cooler?
0 Yes
0 No Not Required
Custody seals intact on sample bottles?
0 Yes
0 No i Not Required
Chain of Custody (COC) present?
0 Yes
0 No
COC agrees with sample label(s)?
• Yes
0 No
COC properly completed
• Yes
0 No
Samples in proper containers?
0 Yes
0 No
Sample containers intact?
0 Yes
Q No
Sufficient sample volume for indicated test(s)?
i Yes
0 No
All samples received within holding time?
0 Yes
0 No
Cooler temperature in compliance?
• Yes
0 No
Cooler/Samples arrived at the laboratory on ice.
Samples were considered acceptable as cooling
process had begun.
0Yes 0No
Water - Sample containers properly preserved
! Yes
0 No
0 N/A
Water - VOA vials free of headspace
0 Yes
0 No
N/A
Trip Blanks received with VOAs
0 Yes
0 No
% N/A
Soil VOA method 5035 — compliance criteria met
High concentration container (48 hr)
F_ High concentration pre -weighed (methanol -14 d)
0 Yes 0 No • N/A
F_ Low concentration EnCore samplers (48 hr)
F_ Low conc pre -weighed vials (Sod Bis -14 d)
Special precautions or instructions included? O Yes No
Comments:
Signature: JlVlorgan Tichacek Date & Time: 02/20/2019 14:15:52
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State of North Carolina
D Department of Environmental Quality
Division of Water Resources
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 conies of the application and
supportin documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permitting 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 .1100. 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.
® l for modified permits, submit the requested information for o& those sites that are new, transferred or affected by the
proposed modification.
3. 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:
♦ New (I) ♦ Renewed (R) ♦ Modified (M) ♦ Transferred (T) ♦ Deleted (D)
® Attach the following in accordance with each status code:
Required Item
1^4
County Board
Notification. doc
Land Owner
Agreement
(If applicable)
%-1A
Setback Waiver
Agreement
An updated vicinity/setback map in accordance with the "Man Guidance
for Residuals Land Application Permits"
A soils and agronomic evaluation in accordance with the "Soil Scientist
Evaluation Policv"
Status
Code
N
R
T I
M
✓
✓
✓
INSTRUCTIONS FOR FORM: LASC 06-16 Page 1 of 3

An updated accounting of the land application site's cumulative
Lllutant loading rates (CPLRs)
Status Code
Required Item N I R T I M
For previously permitted sites without a soil series name indicated in the
Attachment B, submit County Soil Survey Map (or equivalent) clearly
indicate the location of the land application site and in accordance with
the soil map requirements in the "Soil Scientist Evaluation Policv"
Acknowledgement of field transfer from Land Owner (Fields may not
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., latitude 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) • Remote Sensing (RS)
• Conversion from Universal Trans Mere (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: htt ://d nc, ov/about/divisions/water-
resources/ lannin /classification-standards/classifications
❑ Any questions concerning the waterbody and its classification, please contact the Division's regional offices.
❑ A list of the Division's regional offices, their county coverage, and their contact information may be downloaded at:
htt ://de .nc.,ov/contact/regional-offices
❑ General 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 1: 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 http://dN.nc.gov/about/divisions/water-resources/ Manning/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 location 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 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 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 Classifications 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 15ANCAC 02B .0301M.
❑ 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 enterin Georgia or Tennessee shall be classified "C Tr."
Little Tennesse River
Streams entering Georgia or Tennessee shall be classified "C Tr." Such streams in the Savannah
Basin And Savannah
River drainage area entering South Carolina shall be classified "B Tr."
River Drainage Area
Streams entering Tennessee will be classified "B."
French Broad River
Basin
Streams enterina the State of Tennessee are classified "C." _
Streams entering South Carolina are classified "C."
Watauga River Basin
Broad River Basin
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
Streams entering Virginia are classified "C," and such streams entering South Carolina are
Basin
classified "C."
Lumber River Basin
Streams enterin South Carolina are classified "C Sw."
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
Roanoke River Basin
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."
Cho mn River Basin
Streams enter'enterirw Vir inia are classified "C."
Tar -Pamlico River
All drainage canals not noted in the schedule are classified "C Sw." except the main drainage
Basin
canals to Pamlico Sound and its bays which shall be classified "SC."
Pasouotank 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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GRAPHIC SCALE
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The compliance boundary Ls established either 250 ft From the residuals application area or NC-BR-2 I
50 feet within In the property boundary, whichever is closest to the appifcation arm The
review boundary is established midway between the compliance boundary and the
perimeter of the residuals application area. All locations are approximate. FIELDS I — 6

Ill APPLICATION
L
LEGEND
APPLICATION AREA
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UNSUITABLE AREA
WATER
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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
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perimeter of the residuals application area. All locations are approximate.
GRAPHIC SCALE
I" = l 32W
132W 0 1221Y
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LONGWOOD
Fields I - 3

I
LEGEND
V V
APPLICATION AREA
UNSUITABLE AREA
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The compliance boundary is established either 7.50 %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
I'" = 1320'
1320' a 1320'
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Fields 4 & 6

APPLICATION MAP
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The compliance boundary is established either 2 0 fc from the residuals application area or
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review boundary Is established midway becwten the. compliance boundary and the
perimeter of the residuals application area. All locations are approximate.
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NC-BR-2 I
review boundary is established midway between the compliance boundary and the
perimeter of the residuals application area. All locations are approximate.
Fields I - 6

State of North Carolina
Department of Environmental Quality
Division of Water Resources
-Ki
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 conies 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 .1 i00. 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):
[os 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. - .
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: a FP
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)
Fic I M
Q
'g4: TYoS
44 Hb a 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.
his 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 oi• cancels this Agreement.
FORM: LOA 06-16 Page 1 of 3

J, ' STIPIIJLATIONS:
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 parry 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-DWI?, Non -Discharge Permitting Unit, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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 infonn 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 sites) 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 Iand 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.
M. 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 .0105I 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;
4A re -defined compliance boundary is needed for field(s) ID: _ .'Nk-z /'-
(Please include the rationale for the requested re -location oe 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: _ _ _ 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 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.
Landownernname:,�OId5 I� opof 1JC I�C'.7 ! C% ymll. AILC OLOW1 f40o j PraPCI'T� �-hili
Address: Q, 160X 7 2
City: iW h 1 T c ill l % C State: He Zip: 2 & +V 7A
Phone: q r o- O~ 77,2 / E-mail address:
c. Date: 1,0
Signature: 1 —
NORTH CAROLINA, _ COUNTY
I, the undersigned Notary Public do hereby certify that 1-a Ir'- T 1. iA-,. An initials: P personally
appeared before me this day, and, being duly sworn, stated that in his/her presence IA A_, s� f; r}-- signed
the attached document and acknowledged the due execution of the foregoing instrument.
WITNESS my hand and official seal this the day of QIMOe 1' 20 1`f
Signature and seal:
My commission expires: gu. n` R08ERT N. ROTH
6 Lessee's/Operator's Certification:
GUILFORD COUNTY
STATE OF NORTH CAROLINA
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: j JA ✓i S t a ✓�
Address: *5 ( Z' .," L S --
City:. L i rT! t State: 137C.- Zip: _ Z 1.i-lr
Phone: � 10 51 - ? 2 E-mail address: dlw,K S
Signature: 1 64, Date: �� " /-/ Z ��
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:
Signature: _ _ _ Date:
FORM: LOA 06-16 Page 3 of 3

•
0
L�

1. VICINITY MAP
?� Andrew .Jackson Hwy
Z DO
i
1
Ln 8 3 _
`r
h�
Cs,
n
vi
ci
N -
a C
GRAPHIC SCALE
The compliaace boundary Is established either 250 ft frooi the r+eslduals application area or 50 feet Within 1 Y V' V O'V8
In the "e€fy boundary. whichever Is closest to the application area. The review boundary Is established
midway between the comoiance boLmdary and the perimeter of the residuals apOication area. All locations are apwtoxhate. Field q i

APPLICATION MAP
LEGEND
APPLICATION AREA UNSUITABLE AREA
PRNAiE fAei WTA7ER
STREAM ■
■
0
DRAIN
FENCE
PROPERTY LINE
ONSGE HOUSE
OFFSITE HOUSE
Ot1TBUILDINO
WELL
The anVIlara boundary Is estabished elftr 250 It from the residuals appication area or 50 feet %%thin
In the property boundary, ever is closest to the apptratlon area_ The Ceiv1ew boundary Is established
midway between the a moiiam* Wxmdary and the pe n*ter of the residuals application area. Al
bca6ow are approxunaie.
GRAPHIC SCALE
= 661Y
NC-CO-08
Field 1

Q
Z
SOIL SURVEY
GRAPHIC SCALE
1°=4W
The "fir boundary Is pstat>iiM elihet 250 ft from U* residuals applicalon area ar 50 feet vAthin
oly in the pboundary, whkhever Is closest to the appficalon area_ The reldew boundary Is established
midway between the compliance boLrWary and the Wrmter of the residuals application ama. AN
IoC 6oft we approximate.
NC-CO-08
7111

TOPOGRAPHIO TIP
t +
gigs
t2nU1Lit•
�J 10Al.l14BUS COO
till
•� t
1
_ Y
a
19
13WHIC SCALE
11-400'
4W e
The pompkance txundery Is estallaW either 250 ft f6m ttte residuals appucanon area ox 50 feet Wthin N C'CO'08
In the pmpedty boundary, whk)wver is closest to the application area. The teview boundary Is estabished
midway between the compliance bowdary and the perimeter of the residuals application area. DUI
ixatim are approxpmate. Field 1

/d ?.r.�i State of North Carolina
Department of Environmental Quality
'Division of. Water Resources
Division of Water Resources D 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 ori�_i_nal 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):
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. ff 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: __. j Lk "—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 Land Use or Intended Use of Crops
(yes/no) Cropping Patterns
►i eJA - 1 IN RoWW v o 1A V;-Ma i Feed
Residuals Source Special note
(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.
us Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
adall 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 oi• cancels this Agreement.
FORM: LOA 06-16 Page 1 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 H) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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 sites) at any reasonable time for the purpose of determining
compliance with the permit; establish monitoring facilities on or near the land application site(s) as required by the permit; copy any records
that must be kept under the 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.
—t. 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.
IH.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 .01051 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: � , 0 .
(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: _ , 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 ofthe 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 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: %" a L j—jQ C
Address: - q3 Z I W a -r C k Ta W K Roc ef
City: Q !! IC_ 0 ^� State: —ffC Zip: 2 S
Phone: / 1 Q. " 65S ` -99 1-3 E-mail address:
NORTH CAROLINA,,COUNTY
I, the undersigned Notary Public do hereby certify that j d'v i n &"1 — (initialstj 6) personally
appeared before me this day, and, being duly sworn, stated that in his/her presence arxi signed
the attached document and acknowledged the due execution of the foregoing instrument.
WITNESS my hand and official sealthis the 20� day of 0/"3-01-u , 20]..
Signature and seal:
My commission expires:
Lessee's/Operator's Certification:
ROBE. � O.
NOTARY PLY-9jk1.1
GUJ FOR1) COUNTY
STATE OF NORTH CAROLINA
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name: _, _
Address:
City:
Phone:
Signature:
Permittee's Certification:
State:
E-mail address:
Date:
Zip:
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name: _ M % \X o n S Y pt h111
Signature: l► _�/ y��r Date:
FORM: LOA 06-16 Page 3 of 3

0
E

VICINITY MAP
t
Z
t r35
t r�s
ti35 1 vaa
GRAPHIC SCALE
1" ^ 4� W
The compliance boundary Is established elther 250 it from the residuals applcabon area or 54 feet within
NC -Ca_ 15
In the property boundary, whichever Is closest to the application area. The review boundary Is established
midway between the compliance boundary and the pedineter of the residuals application area. All
locations are approximate.
Fields 2&3

APPLICATION MAP
r "
d
•
-
J
LEGEND
APPLICATION AREA UNSUITABLE AREA
— — — — —
PRIVATE ROAD CD WATER
GRAPHIC SCALE
-- — — ---
STREAM! ONSITIE HOUSE
V = 660'
— !
DRAIN OFF$ITE HOUSE
FENCE U OUTBUILDING
PROPERTY LINE 0 WEU
The compliance boundary Is established eldw 250 ft Wm the residuals application area or 50 feet Wt*
N C-CO-15
in the property boundary, whicfrewer Is closest to the application area_ The review boundary Is established
midway between the compliance boundary and the perimeter of the residuals application area. Al
Ioe:alions are appoxhate.
Field 2

APPLICATION MAP
v-v- -v-
1.iA-ss
1 rP+rLlr%
APPU TION AREA
®
dThSUITASIE AREA
— — — — — — PRf'VATE ROAD,
Ck
WATER
— — — STRrFAM
ONSITE HOUSE
— ' — DRAIN
OFFSITE HaJSE
FENCE
El
OUTs"ILDING
PROPERTY LINE
0
WELL
The tormpllante boundary Is established elbvr 250 It from the residuals appiraion area v� 50 feet within
In the property boundary, whi Never Is dosest to the applicaion area The rWew boundary Is estabished
midway between the compliance boundary and the perimeter of the residuals application area. Al
locations are approximate.
GRAPHIC SCALE
V = 66©`
csa0 6sr.•
NC-CO-15
Field 3

SOIL SURVEY
LA
Ilk
vw
AR
i x
44/0
r ►
� , • , � s`�'R��r'.k•.Irk-� .* , . 'gyp ' �� �. .
GRAPHIC SCALE
1" = 400'
4W 4 4W
The compliance boundary is established either 250 tt from the residuals application area or 50 led within N C-CO-15
in the property boundary, whidwer Is closest to the application area. The resew boundary is estabished
midway between the compliance boundary and the perimeter of the residuals application was, AM
locations we approximate. Field 2

SOIL. SURVEY
l
~i
it
17
rr I.
' y• � r c ffr
mat
R
GRAPHIC SCALE
1„=6W
ssa a OW
The compliance boundary is estabashed either 250 It from the residuals application area or 50 feet wit*
N C_CO_15
In the property boundary, whichever is dosest to the appnca>fon area_ The review boundary Is established
midway between the compliance boundary and the Wrneter of the residuals application area. Al
locations are approxhnate.
Field 3

n TOPOGRAPHIC MAP
'Muff
vz
9
01131M RM
GRAPHIC SCALE
III = 400'
4C
wacra'malvv
sh6w--m
0 f1rul P, US t.T4
i A 11 Lill-
The compliance boundary Is estatAftd either 250 ft from the residuals application area Of 50 feet Wt*
in the "edy bourvdarywhktwvef is closest to MaWfleation area The (eiview boundary is established
midway between the compliance boundary and the perimeter of the residuals application area. All
locations are aproximale.
a c v- a
tot
SED r
NC-CO-15
Field 2

,%Off
0
TOPOGRAPHIC MAP
At.
All.
?Xb^
Sj
—LAN
GRAPHIC SCALE
V = 6W
ew 0
The compliance boundary Is established elber 250 It hm the residuals application area or 50 feet within
NC-CO-15
in the
pmerty boundary, whdtevef Is closest to the application area. The review boundary is established
midway between the comoiance boundary and the perimeter of the residuals application area. M
IOU60U are awoxirriale.
Field 3

State of North Carolina
Department of Environmental Quality
'DWR(a Division of Water Resources
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 oriLinal and two copies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non-Dischar - e Permits 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 . i 100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Owner Agreement (FORM: LOA 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.
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) (Le., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Lease Land Use or Residuals Source Special note
Site/Field ID Intended Use of Crops (no-till/over-seed/
(yes/no) Cropping Patterns (optional) pasture)
IL 140
�► r d
X-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.
"his 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

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 In are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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
Iand 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.
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.
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)
J�LA 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 field(s) be removed from the previously permitted residuals land application program and transferred
into the new program;
(Name ofthe 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 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: __7' t' k J-" _Ir �/• / 1 1 _C . n C ! I
Address: 0
7 7 _ 01-�'
City: L A A. a lWA d le A M A WState: Ad_ Zip: —..� Y� d
Phone: "" �i �_ E-mail address:
Signature: " y _ Date: 0
NORTH CAROLINA, COL4U_�.
COUNTY
I, the undersigned Notary Public do hereby certify that Millon(initials personally
appeared before me this day, and, being duly sworn, stated that in his/her presence jr1 Lei i — signed
the attached document and acknowledged the due exution of the foregoing instrument.
WITNESS my hand and off c' 1 seal this the _,day of. JJMIb,920 )'J—
Signature and seal: t�
My commission expires: . ROBERT M. ROTH
PS th NOTARY PUBLIC
GUfLFORD COUNTY
STATE OF NORTH CAROLINA
Lessee's/Operator's Certification:
I certify that I have read thisAgreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lesseeloperator name: w
Address:
City:
Phone:
Signature:
Permittee's Certification:
State:
-E-mail address:
Zip:
Date:
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: M % r" S VA v\y%
Signature: CV\ %)tL—. $,
Date: tt l 20 11C
FORM: LOA 06-16 Page 3 of 3

0
0

0 VICINITY MAP
cc
Q � ;
a
c
9�
GRAPHICAI= SGAL
4 1" = ,OW
4.W 0 4-OW
r ... �
E
The: complaree boundary is estabiisbW ener 250 ft from Otte residuals appfic"on area or 50 feet wiihln N C-CO-1 G
in the property boundary, whichever is Osest to fire applicalion area. The review b3undary is Established
midway between the compliance boundary and ti'te perimeter of the residuals application area. Rp
Wmlonsare approkmate. Fields 1-4

APPLICATION MAP
. + R n+•�� :..
4Li
7~
LEGEND
APPLICATION AREA ® 1UNSUITABLE AREA
PRPIATE ROAD WATER GRAPHIC SCALE *
sT> ONSTM HOUSE 1d = 66(Y
DRAIN OFFSTE HMSE �• ,
�— a- FENCE El OUTBUILDING
PROPERTY LINE 0 WELL
The cwVbr4o boundary Is established either 250 R from the residuals application area or 50 feet vrtthtrt I NC—CO-1 V
In the property boundary, wihiheyer Is doses# to the application area_ The review boundary Is established
midway beWeen the comoiance boundary and the penrneter of the residuals application area. AN
lonalisns we approximate. Field 2

CD
APPLICATION MAP
VA
r �r
.. 1 @
T'
r
sn
✓.
4
LEGEND
APPLICATION AM � UNSUITABLE AREA
®o
PRIi ROAD WATER
GRAPHIC SCALE
STREAM ONSITE HOUSE
V = 66f)'
— -
D NN ■ OFFSITE HOUSE
FENCE ❑ OUTBUILDING
PROPERTY LINE 0 WELL
The conViiara_ bound.ary Is established elther 250 fl hm the residuals appliceftn area ra 50 feet Wthln
NC-CO-16
In the praaegy b=dary, whichever Is dosest to the appteabn area_ The review boundary Is established
midway between the compliance bocr'idary and the pOmeter of the residuals applii area, An
-
lo iris are apptexmate.
Fields 4A&p

SOIL SURVEY
.r
r a,
`Rr -
.r
GRAPHIC SCALE
V = 4W
The boundary is estabtishad elther 250 t3 from the residuals application area o€ 50 (0.010. thin 1 V C-CO-16
In the poperty, boundary, whikhmer is closest to tt aWicailen area. The miew boundary is established
midway between the compliance boundary and ftte pedmter of the residuals apo ication area. M
l=6"amsppmkmate. Field 2

0 SOIL SURVEY
a
z
U)
r '
powe
A
F
=r
GRAPHIC SCALE
rip =6,
6%- 1 0 6w
The co MBarwe boundary is establslvd ON( 250 ft from the residuals applicatan area of 50 feet %ithun N C-t ,O-
In the pVarty boundary, whichever Is closest to the application area_ The review boundary Is estabisW
midway between the compliance boundary and the perimeter of the residuals applicatiort area. M
locations are approxhate. Fields 4A&B

TOPOGRAPHIC MAP
GRAPHIC SCALE
�1
1
V"I'l4 R)" a
NC-GO-16
Field 2

TOPOGRAPHIC MAP
0
i
t
GRAPHIC SCALE
1' = 660'
The wn#iarwe bour►dary Is established elftr 250 ft from the residua6i applcagon area or 50 feet within
H C-CC_ 1
In the property boundary, whichever Is closest to t1he application area. The review boundary Is established
V
midway between the cornoiance boundary and the pedmeter of the residuals applicatbn area. A91
Iowbm areappfmximate.
Fields 4A&B

eA�!a ' ,ek IlGYd xe,
- DWR cv-l6
Division of Water Resources
State of North Carolina
Department of Environmental Quality
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 note(]. the A >licant shall submit one on»in al 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 Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. ff 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
A�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 landolyner or his representative hereby permits:
Applicant's name: __ _C- f" U jk- - . ---
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:
Lease Land Use or Residuals Source
Special note �
Site/Field ID Intended 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.
'its Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
- tall 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 ok cancels this Agreement.
FORM: LOA 06-16 Pagel of 3

L " 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 Iand 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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
Iand 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.
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 laud 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.
M. 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 .01051 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;
COA re -defined compliance boundary is needed for field(s) ID: C — 6 6 - Z i
7
(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: _ 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 allomey 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: 911 B r f N K I C ly ife a d
City: c 0 State: tvm —.23
Phone: f E-mail address:
Signature: Date:
NORTH CAROLINA, Lk ��i Y�� , COUNTY
I, the undersigned Notary Public do hereby certify that rAjP j y y 1,r, v A Qnitials:gA h) personally
� 7-
appeared before me this day, and, being duly sworn, stated that in his/her presence to 5 signed
the attached document and acknowledged the due execution of the foregoing instrument.
WITNESS my hand and official seal this the day of e�- &Est` 20�
-Signature and seal:
My commission expires: ="F
ROTHGSTATE
Lessee
's/Operator's Certification:
I certify that I have read this A ureement 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 herebyagreeto abide by the stipulations and restrictions as specified herein.
Signing official name: J % )':T p r* 5 V �►
Signature: � " \= . S. V t,.—, Date: it
FORM: LOA 06-16 Page 3 of 3

0
•
C:

VICINITY NEAP
Z
Swish Moto € 6
1843 �i
�Sr
Yam,
IIpf
CIA
C 1
n
M
� 1Fa3
CHIC SCALE
2,00
l � �
The ca*Iance boundary Is established elther 250 8 from ft residuals application area o€ 50 feet within N C-CO-1 l
In the pie. y bounday, whichever Is closest to the application area. The review boundary Is esMshed
nWway between the compliance boundary and the !teeter of the residuals application area. AN
loran Field I A' l A, 3 r4A,4B ,5
m ximate,

APPLICATION MAP
LEGEND
APPLICATION AREA
�
UNSUATABLEAREA
- _ - - - - PRIME ROAD
WATER
STREW
ONSITE HOUSE
— - DRAIN
OFFSITE HOUSE
FENCE
❑
ouTSUIUIING
PROPERTY LINE
0
wELL
GRAPHIC SCALE
V=66V
ssu° o
NC-CO-17
Fields 1 A&B

_ APPLICATION MAP
a
I
V
{Lc
C *
r s .
LEGEND
APPLICATION AREA ® t1NS13ETABLE114EA
PRIVATE ROAD WATER GRAPHIC SCALE
—. - - _-- STRE M ONSTM HOUSE 1" = 66V
csa b
- DRAIfa OFFSITE HMSE
aF - -- — FENCE ® OUTBUILDING
PROPERTY LINE: 0 WELL
The Coit'i Ura boundary Is established 0her 250 It from the reslduals Wiuton area w 50 feel WU* 1 v C-CO-1 l
In the poperty boundary. whichever Is closest to the application area. The m4ew boundary Is established
Midway between the compliance boundary and the perimeter of the residuals ap hcatia1 area. Ati
Icatirins �a�proIate. Fields 3-5

f . . RIL
MmA

I
TOPOGRAPHIC MAP
In -I 14 usiv
(*E1,1. UT r, I UUS .-
GRAPHIC SCALE
Im = 4001
by D 4w
The cm-oplarioe bouWary I� estabished 010,W 250 ft ftn the resIdUSIS aPP50890n area or 50 feet Thin
in the pk*edy bounft!Y. whkhever IS closest to the applicalon area The review boundary Is established
rnid%vy between the compliance boundary and the p#A rneter of the residuals application area, Al
Iowbrts. am a*roxhate.
NC-CO-17
Fields 1A&B

TOPOGRAPHIC MAP
AAAAAA
1'
GRAPHIC SCALE
i" = 660'
s�
The ompbrice bourdwy Is estabished either 250 ft !torn the Iesldoals application ema os 50 teet Wthtn N C—CO— 17
in ttre psapety bounday; which"er Is closest to the applicatton area The reiAew boundary Is established
midway between the compliarm bacrndary and the peOmeter of the residuals applicakan ama III
looatonsate approxknate. Fields 3,4A,4B,5

State of North Carolina
f) (� " l Department of Environmental Quality WR Division of Water Resources
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 Water Quality Permitting Section's Non -Discharge Perrrmittina 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 treato�ent plant or other type residuals) in accordance with 15A NCAC 02 T . i i 00. 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 Land Application Site Certification (FORM: LASC 06-16) form. Please
o 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.
,j 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: C4 A ---
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (Le., 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 Patter-
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
eflf1^17
/� ip
OY
A�rM er;�
3 �
Pm
k h�l ' �',
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
As 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 oi• cancels this Agreement.
FORM: LOA 06-16 �� Page 1 of 3

I STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the 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 parry, 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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 Pemuttee, 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.
at. 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 laud 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 Iand 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.
111ALTERNATIVES 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;
MA 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: _ _ _ 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 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: _ 4C/F d 4�J
Address: 1I 0 G ', / 1// 0V
City: _,0 State: Zip: —��
Phone: gto9 W 41 V 4 Email ddress:
Signature: Date: "' +►
NORTH CAROLINA, COUNTY
I, the undersigned Notary Public do hereby certify that _y i ll ao ouk (initials jq 6) personally
appeared before me this day, and, being duly sworn, stated that in his/her presence Ak,Lm 4pA1tc signed
the attached document and acknowledged the due execution of the foregoing instrument.
WITNESS my hand anWcial seal this the ON
of � , 20 — -
r � . -%
Signature and seal: F Z d►P-
My commission expires: ESTATE
MT-.n� �e
NOTARY PHRUC
ILFORD COUNTY
Lessee's/Operator's Certification:
OF NORTH CAROLINA
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: aalws
Address:
City: State: Zip:
Phone: E-mail address:
Signature: Date:
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: `�0 S V A
Signature:
Date: 1a0fs
FORM: LOA 06-16
Page 3 of 3

0
0
0

VICINITY MAP
MOM-- ami
ct
z
5est
cc
3
0
�t®
GRAPHIC SCALE
1' = ZOO
M, a 20E
The owpliera boundary Is estabished el her 250 0 from the resldaats a0ficdtion area or 50 feet adth NC-CO-2 1
In the po", boundary, whichever Is closest to the application area. The review boundary Is estabished
midway between the comoiance boundary and the penmeterr of the residuals application area. N
locations are approximate. Fields 1 `3

f
APPLICATION MAP
.. t�N'N
r
i
.+ ..r r - - ty ►r
A r • � -.R
EGEND
APPLICATION AREA UNStATABLE AREA
— — — — — _ PRIVATE ROAD WATER
STREAM ■ ONSITE HOUSE
-- DRAIN ■ t FFIS►TE HOUSE
�— FENCE OUTBUILDING
PROPERTY LINE 0 WELL
The "iiaxe b utrwarp Is established ellhe€ 250 ft from the residuals application area of 54 feet wtthon
In the propetfty boundary; whichevo is eloedt to the appllcagon area- The re+dew boundaryis established
midway between the comoiar a boundary and the perimeter of the €esiduals application ales, AD
locations we approximate.
r I
4
GRAPHIC SCALE
1" = 66Y
' 0 wj
I p -q
.
NC-CO-21
Fields 1-3

0 SOIL SURVEY _
1. 1 1121 C111
4P
kI
r.
"y-
r
s r �
4
GRAPHIC SCALE
1" = 4W
Uti 0 4W
The complIan teary is estabished elther 250 ft from the residuals application area or 50 lot Wthin 1 V C-CO-2 1
In the property boundary, whichever Is closest to the application area The rooiew boundary Is established
midway between Qir: compliance boundary and: the perimeter of the residuals applicatW area, , l
loca ars are approximate, Fields 1-3

TOPOGRAPHIC MAP
GRAPHIC QQSCALE
t
1" =
The omplianee boundety is established elther 250 It (ter the residuals appt caton era oF 50 (eel Wthin N G-GO_21
in the "erty boo-ndary, whithever is dosed to the application area. The reidew boundary Is estabisiml
midway between the compliance baEmdary and the perimeter of the residuals application area. Ail
locati m ace appfoxhlate. Fields 1-3

a L„ . /'Y � State of North Carolina
IDWRc, 4i — 9 1 Department of Environmental Quality
Division of Water Resources
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 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 02 T .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 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.
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: 4k
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (Le., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Site/Field ID Lease Land Use or
(yes/no) Cropping Patterns
Residuals Source Special note
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.
,is Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
.fall 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:
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 11) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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.
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 Iand 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.
M.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;
1. A re -defined compliance boundary is needed for field(s) ID: LO m Z- V
(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: 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 ofthe 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: A ! je o Alz o 4. j, 1 4 Pis _ --
Address: � � / f r� 0/-I V e
r
City: K ITe Y% State:_ A6C zip: Z a 4f 1
Phone: /* — � - ai"ddress:
Date: _'' 1 _ 1
V NORTH CAROLINA, l,O I GAS � ,,c COUNTY
I, the undersigned Notary Public do hereby certify that &j; to P-3oC �k (initials14,(6 ) personally
appeared before me this day, and, being duly sworn, stated that in his/her presence 414 ►u signed -
the attached document and acknowledged the due execution of the foregoing instrument.
WITNESS my hand and offici 1 seal this the ( day of Df'--��� 20-
Signature and seal: � _ o
iv ­
My commission expires:
Lessee's/Operator's Certification:
ROBERT N. ROT
NOTARY PUBLIC
STATE OIFPNORTH CAROLINA
I certify that I have read this A Bement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lesseefoperator 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: _ MIS `Nan s v JP, Y11f\
Signature: S v Date: `� a
FORM: LOA 06-16 Page 3 of 3

0
L
0

d
VICINITY MAP
1K
GRAPHIC SCALE
1" = 1,OW
1„E%ArJ' Q 1,U3�'
The complla tce boundary Is established elther 250 ft (MM the: residuals appkation area or 50 feet withm
In the propedy boundary, whichever Is closest to the applfcabn area_ The re Aew boundary Is established
midway between the comp tame boundary and the perimeter of the residuals application area. Ad
locations are approximate,
1552
NC-CO-22
Fields 1-10

APPLICATION MAP
it 1 1 ' � •A •
i -
`r •,t fir=
r O A
4
r '4�
i
LEGEND
APPLICATION AREA UNSL4TABLEAREA
- - - - - - PRIVATI= ROAD WATER GRAPHIC SCALE
STREAM ONSITE HOUSE 1" = 66V
seu' n
--- DRAIN OFFSITE HOUSE ` ;
. FENCE a ouTBultDiNG
PROPERTY LINE 0 WELL
The cornpsance boundary is established elther 250 ft from U* residuals application area w 50 teat within NC-CO-22
In the property boundary, whkhever Is closest to the application arm The review boundary Is established
9Wway between the compliance boundary ad the petirmter of the residuals applicati'at area. All
locations are appmxomate. Fields 1-10

SOIL SURVEY
GRAPHIC SCALE
1" = 669
The wmpitaxe boundary Is estabished either 250 ft from the residuals apptitelJon area or 50 feet within
In the property boundary, whktwfer is closest to tMappltcagon are The review boundary Is established
midway beWmen the eomoiance boundary and the perimeter of the residuals application area. AD
locations are approximate.
NC-AGO-22
Fields 1-10

TO"POGRAPH IC MAP
0
(D
i
d',1g'�;i,l-E- '�•1E kt ., r't 7,1E �11,;011i�i�
GRAPHIC SCALE
1" = 660'
6W D 657
The m mpbru bourWary Is established elther 250 ft from the residuals appleation area or 50 feet vdthin I V -CO-22
I n the grope ty boundary. whietrewer Is closest to the application area. The review boundary Is established
midway between the compliance boundary and the perir€u;ter of the residuals applicat an area. M
locations are approximate. Fields 1-1 Q

State of North Carolina
nw
rj -� Department of Environmental Quality . ®r-
Division of Water Resources
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 Water Quality Permitting Section's Non -Discharge Permittin; 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 Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. ff 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: PT A
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:
Lease Land Use or Residuals Source Special note
Site/Field ID Intended Use of Crops (no-till/over-seed/
(yes/no) Cropping Patterns (optional) pasture)
All; f1drI `et l
M2..�-�.'., q
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.
his 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 ok cancels this Agreement.
FORM: LOA 06-16 - .... - Page 1 oB

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 sites) to a third party, the landowner shall
be responsible to ensure that the third parry 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 li) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR DWR, Non -Discharge Permitting Unit, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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 leacbate, 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.
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: _ is currently permitted under another
residuals land application program; Permit Number WQ:- ___ _ The Iand 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 ofthe 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 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: r!!me .r, 6,
Address: to -9D XF6 5 O iZr "A19
City: J,A) 141 TEV iLLr
State: %'V Ci
Phone: 01 b — � U -7 - 4 7 7Z E-mail address:_
Signature: ,dam. C,
NORTH CAROLINA, 0L)1U-W, b (.c Z _ COUNTY
Zip:
Date: Oc. f A3 --;Q V l
i
I, the undersigned Notary Public do hereby certify that ---T- ,fea e
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the 17 j
day of
Signature and seal: C TS ?� _ L,II I A `•�
My commission expires: _L _ _ ,3� X3
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: �U Lc/ _►'r
Address: f/s 2c
City: — ) V1 I L L L
Phone:
Signature: _
Permittee's Certification:
State: -_ I V 4-- Zip:' f
E-mail address:
Date: jo "94,o -
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: K . \Non S VA VNn
Signature: _ -ok Date: _��► I
FORM: LOA 06-16 Page 3 of 3

DWR-
Division of Water Resources
0 State of North Carolina
Department of Environmental Quality
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 final and two cosies 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 . i i0u. 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 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.
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) (ie., 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)
Iff
3 4-3
-
-
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.
Is Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
snail 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

L " STIPUI ATIONS:
I. 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 In are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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.
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 Iand 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 Iand
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 .0105ih1 allows the
compliance boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance
boundary provided the groundwater standards can be met at the newly -established compliance boundary. Please mark one of the following;
k,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: 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 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 sites) as specified
herein.
Landowner name: - - -- -
Address: i -- --- - - -- -
City: ��� G 4 i✓i State: >�l Zip:
Phone: ' 3 r m afiUCC31: 7 ,v
C�,l�� ate:
Signature:
NORTHCAROLINA, 0 _ COUNTYr'Q�, p
I the undersigned Notary Public do hereby certify that 5040 , , -. -`_ -ry��� 4knes
- -- —
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the _ .���oX�gy CIINIiIIi�������
- - -
OG 0 Q 20- -
day of _ -
c,,�
Signature and seal: --
My commission expires: - -
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: l%
Address: < < d
city:i' --.� State:7�. -
Phone: 2if E-mail address: -
Signature: Date: i9- OZ 4,
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:00
Signature: P'1, V t�- Date:
V- .---
FORM: LOA 06-16 Page 3 of 3

State of North Carolina
�� �z Department of Environmental Quality
1-DWR Division of Water Resources
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 conies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Von -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):
f 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.
Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
M-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: a —
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (Le., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Site/Field ID
Lease
(yes/no)
"Useor
Cntended
He
Use of Crops
Residuals Source
(optional)
Special note
(no-tiWover-seed/
pasture)
�e �'C a - Z
/V
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.
his 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 parry, 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 Il) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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 Iandowner 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 patters, 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 patters 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.
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.
M. 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 .0105th) 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;
F�,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 -defied 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 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 ks4cd 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:
Address: _A l'e i I - N!
City: State: 1 �,-� - zip: -7
Phone: 3 3 _7 - 311 _ E-mail address: r;e a) V4 4 60, Cowl
Signature:
�c' - A— Date: C 12
�
NORTH CAROLINA, Y COUNTY q
I, the undersign.ed Notary Public do hereby certity that cart!
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the i
day of v O�D V'W
Signature and seal:
My commission expires:
Lessee's/Operator's Certification:
- - Notary.
Forsyth Co., North Carolina
MY Commisslon Expires May 22, =1
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: S
City:. / I! I l lA.- L _ State: —�� -- .. zip: d d�
Phone: 0 p raj O — E-mail address:
Signature:
Permittee's Certification:
�. 1
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: —� A'f� - - - —.
Signature: f�1 Date: --
FORM: LOA 06-16 Page 3 of 3

0
0
0

VICINITY MAP
?4 06
q1J
4%
�auq"",-
Abouridant Life
Fy
GRAPHIC SCALE
I" = 4,000'
4,000' 0 4,000'
(he 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
I perimeter of the residuals application area. All locations are approximate.
NC-CO-29
FIELDS 1 13

APPLICATION MAP
LEGEND
WATER
APPLICATION AREA
ONSITE HOUSE
- — — — — - PRIVATE ROAD
STREAM
OFFSITE HOUSE
OUTBUILDING
- DRAIN
WELL
— PROPERTY LINE
fhe 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'
CO-29
Fields 4 - 14, 12

N
TOPOGRAPHIC MAP
GRAPHIC SCALE
" = 1000'
1000, o 1000,
ne 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.
ChrirjL,ouiii
CO-29
Fields I - 13

� � Apr - _ .. -_ ! i y -� • l ,,:
zlop
o DIN,

SOIL SURVEY
GRAPHIC SCALE
I " = 660'
660' 0 660'
,'he 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.
CO-29
Fields 4 - 10, 12

- �, �ta► l`� M�
g, ,
k�
Division of Water Resources
H 0 bAs State of North Carolina
2 G Department of Environmental Quality
7 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 Aimlicant shall submit one original and two copies of the application and
su } ortin documentation
For more information, visit the Water Quality Permitting Section's Non-Discharee Permitting Unit.
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class S residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 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 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. -
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: —L.p eL4ik
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 j Land Use or
es/no Cropping Patterns
(y ) pp g
�
SIO IV
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
lob
P krr a
NiMAJ =��J
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.
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

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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtaina 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 sitc(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 time 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 Iandowner 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 o% and 12 months after termination of, this Agreement.
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 Iand 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.
TII.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;
R .A re -defined compliance boundary is needed for field(s) ID: �Q'"�
(Please include the rationale for the requested re -location of the compliance bounddry &id 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: is currently permitted under another
residuals Iand 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 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: T o ti tiy R 0 b bf
Address:a
City: C _h fA d h O GA le ff a State: _ �� _ _ - — Zip: } 41-3
Phone: 710 /0 - / J ` 6 E-mail address:
Date: ? -1) -) 9
NORTH CAROLINA, &)L&^�U-5 COUNTY
,, 7
I, the undersigned Notary Public do hereby certify that o n `6u, k n, 0"t (initials:G (,) personally
appeared before me this day, and, being duly sworn, stated that in his/her presence /rp,,.,,f��� signed
the attached document and acknowledged the due execution of the foregoing instrument. r°
WITNESS my hand and official seal this the day of D 20 I
Signature and seal:
My commission expires: AZW, _ ROBE-T
NOTARY PUBLIC
-'i-r RD COUNTY
Lessee's/Operator's Certification: STATE OF NORTH CAROLINA
I certify that I have read this Agr-ement and do hereby agree to abide by the stipulations and restrictions as specified herein..
Lessee/operator name: !N
Address:
City: State:
Phone: E-mail address:
Signature:
Permittee's Certification:
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: M.\N 0 r� s- � AY1 r,-
Signature: ���-!S. VCR -
Date: hl.Q
FORM: LOA 06-16 Page 3 of 3

0
0
0

VICINITY MAP
rn �i
V
Z i
�aa
lk TD!
iAd
a`
r3
4
n
8s'�vtrd5m nr! cr
a�
C��bt fld
r 36T
G }'hI4S Lq
63
'�nbuC�
W q RV
cd
�FCd 7i��� Qp
4�
Rfi
GRAPHIC SCALE
4° = 2,50V
0 2.6W
The compliame boundary Is established either 250 ft from the residuals application area or 50 feet t►AMM NC-CO-30
in the property boundary, whichever Is closest to the appllcation area_ The review boundary Is established
rnidway between the compliance boundary and the perimeter of the residuals application area. AM
locations are ap"Xi mace. Fields 1-7

•� APPLICATION MAP T
� a
f"
GYM
�ya, �q 4
dk
T`�iy.f
• b f, .a f y •�r'Ir•
Ar
Yi~ •fie - �~ A.
F
/ .
LEGEND
APPLICATION AREA UNSUITABLE AREA
PRIVATE ROAD WATER GRAPHIC SCALE
- —..•, STREAM ENISITE HOUSE
"= 66V
,�aY a rar.
— - — DRAIN OFFSITE I4O;JSE
FENCE OUTBUILDING
PROPERTY LINE 0 WELL
The wmplanc* troundary is established alther 250 tt from the residuals apprca�ion area of 50 feet within NC-CO_30
In the pmp" boundary, whichever Is dosest to the application area_ The teAew boundary Is estabished
midway between the compliance boEmday and the pecjrneter of the residuals application area, AM
Imdonsare *Mxhate, Fields 1-5

APPLICATION MAP
TV
LEGEND
APPLICATION AREA � UNSUITABLE kREA
®— PRIVATE ROAD WATER
_.. - STREAM ■ ONSITE HOUSE
DRAIN ■ OFFSITE HOUSE
— FENCE n OUTBUILDING
PROPERTY LINE 0 WELL
The compliance boundary Is estabished either 250 R from the residuals application area or 50 feet Wthln
In the prope tty boundary. i klmer Is closest to the application area_ The review boundary Is established
midway between the compliance bowidary and the perifneter of the residuals appliCation area. A9
I&tations are approximate.
This
I HINSON RD
GRAPHIC GRAPHIC SCALE
1" = 66V
£g� 0 6W
NC-CO-30
Fields 1-5

I
SOIL. SURVEY
GRAPHIC SCALE
1 o = 6W
66cr Q em
The € ompliance bourndary is estabyshed aldwr 250 It from the residuals application area or 50 feet Othin
In the property boundary, whirtmer is closest to the appiirAtIon area The review boundary Is established
midway bewmn the compliance bowndary and the perimeter of the residuals application ama.. Al
locations are approximate.
NC-CO-30
Fields 1-5

SOIL SURVEY
GRAPHIC SCALE
1IF = 6W
The compaamtce boundary Is estabished either 250 tt trom Ow residuals application area of 54 feet within
In the p etty boundary, whichever is closest to the application arm The rNew boundary Is established
midway between the compliance boundary and the WrrRter at the residuals apOl atierr area. AD
Iocakns are appma hate,
NC-CCU-30
Flees 6.7

TOPOGRAPHIC MAP
cr
4
i
GRAPHIC SCALE
V = 680,
E4!iY fk
The ctimplkar5te 6oundary [s estabM$had elftr 250 ft from the residuals application area c15R feet Wthln N C-+�G_30
In the p�c ody bo�:ndaty, whkhever I$ closest la tho apprcajon arm The rNow boundary is astabished
midmy betfeen the complianw boundary and the *jreter of the residuals appiicaW ama. AC
,, at;ons am apomc mate. Fields I -5

T
TOPOGRAPHIC MAP
7
GRAPHIC SCALE
1" = 660'
6W o 6W
The corIVIlance brournfary is estabtlstted either 250 It from the res►duals apphogon area W 50 feet within NC 'CO'30
I n the property boundary, whichever Is dos .W to the apoicatlon arm The review boundary Is established
midway beMwn the compliance boundary and the pe meter of the residuals application area. M locaatitmsamapproXimate, Fields 6-7

If
a-p-.3,&
State of North Carolina
Department of Environmental Quality
Division of Water Resources
Division o€ 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 Water Quality Permitting Section's ldon-Dischaf -e 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 02 T .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 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.
Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
6--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) (Le., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Site/Field ID
Lease Land Use or
(yes/no) Cropping Patterns
f 9.00JR1 OrOA44
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
-- 'Mal
p
I o oe
S% p Q'M�
0 ' YIf o
f r e F�0. 4
H d1 ■ M
`�1
'd l g"Ko;
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 oi• cancels this Agreement.
FORM: LOA 06-16 Page i of 3

;i _ STIPIIILATIONS:
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 m are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR DWR, Non -Discharge Permitting Unit, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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 sitc(s) at any reasonable time for the purpose of detemmining
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.
1.1. 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 Iand 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 .0105ih1 allows the
compliance boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance
boundary provided the groundwater standards can be met at the newly -established compliance boundary. Please mark one of the following;
�XA 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: 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 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: k b el- C-7-c d w 1 d
Address: 16 -Z 19 Pe a-c dux . Rv ad.
City: C_ h.&J 12e ks eW State: C Zip: A 81
Phone: q /d -A 14 el " 46 /7 91 E-mail address: _
Signature: Date: _ _
NORTH CAROLINA,COUNTY
I, the undersigned Notary Public do hereby certify that Melvt i 7 t l (initials:146, personally
appeared before me this day, and, being duly sworn, stated that in his/her presence z rn signed
the attached document and acknowledged the due execution of the foregoing instrument.
WITNESS my hand and official seal this the �h day of __ , 20�.
'Signature and seal:
My commission expires: e Z;,a ` ! G _ ....
Lessee's/Operator's Certification:
----• ,.. 11 n
NOTARY PUBLIC
G(MFORD COUNTY
STATE OF NORTH CAROLINA
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: Sa oe---
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: M� �Td .r► +rp1�h�'1 —_--_. __ .
Signature: Date:
FORM: LOA 06-16 Page 3 of 3

Ll
0
0

0 VICINITY MAP
gelarood,
z
V)' seal
!S4!
Ia2s'
i3pICA
3 Unlck+.A� ls51
1$d9
swim HolcF .
d
1 el3
—M
C
GRAPHIC SCALE
1° = 4,000'
Epp Q 4
� 1
T,he compliance boundary Is established either 250 ft fmm the residuals application area or 50 feet Wthin N C-ea-36
In the property boundary, whkJwve Is closest to the application area. The review boundary Is established
midway between the compirance boundary and the perimeter of the residuals applicaltimn area. AN
locations are apprmximate. Fields 1-5

0
APPLICATION MAP
Ix
�-
r
a.
LEGEND
APPLICATION AREA UNSUITABLE AREA
- -- - - - PRIVATE ROAD C �w� WATER
GRAPHIC SCALE
STREAM ONSITE HOME
1" = 66V
-- - — DRAIN OFFSITE HOUSE
0 6W
FENCE ❑ OUTBUILDING
PROPERTY LINE 0 WELL
The c lianee boundary IS established elfte 250 it from the residuals application area o: 50 feet within
1 C-CO-36
In the properly boundary, whdm. er Is doses! to the application area. The review boundary Is estabished
midway between Ole compliance boundary and the perimeter of the residuals applicaion area. Al
locations app nat
qe, Field
are X
l

APPLICATION MAP
0
z
r
w
'
LEGEND
APPLICATION AREA UNSUITABLE kREA
PRIVATE ROAD w 3 WATER
GRAPHIC SCALE
-- - - -,--
STREAM ONSITE HOUSE
--. - --�
itF`
GRAIN . OFFSITE HOUSE
n 6W
- .._
FENCE OUTBUILDING
PROPERTY LINE 0 WELL
The compliara boundary Is pstabished either 250 It hm the residuals application area w 50 feet rclthbn
I C-CO-36
In the prppe,•ty boundary, whichever is closest to the applfeatfan area The reAew bounidaryIs estabeshed
midway between the compliance boundary and the perimeter of the residuals application area. AB
Iocatfortt are approxhate.
Field 2

cic,iL
}
�1
�l
f�
•
.`
� xo
f� i
■
■

0
SOIL SURVEY
Z
flf1
i
Y
�L
GRAPHIC SCALE
in a
I �
The cvmpllance bwWary IS established elther 250 ft front the residuals appicatton a tea cx 54 feet within NC _CO-36
In the propeity boundary, whichever Is closest to the applltaffon area. The review boundary Is established
midway between the cornplianoe boundary and the p loiter of the residuals application area, All
locations ate approximate. Field

�y SOIL SURVEY
K ,
� t
• w
I +
t
GRAPHIC SCALE
1"=669
0 6W
The cOVISrtce boundary is estebyshed either 250 It from the residuals application area or 50 feet within N C-CO-36
In the property boundary, whomever Is chest to th$ application arm The review boundary Is estabished
midway between the complianne boundary and the perimeter of the residuals applieabon area. AD
IocaGons are approximate. Field 2

0 SOIL SURVEY
� V
-t
C�i f
T f f'
GRAPHIC SCALE
1"y669
R(y
The "Ilance boundary is estabdshed elther 250 ft from the residuals application area ot 50 feet within N C-CO-36
in the property bowtdaty, whichever Is chest to Me application area- The review boundary Is established
midway betvieen the compliance bowdary and the perimeter of the residuats application area.. Al
Ideations are approx, hate. Fields 3-5

Q
Z
}
TOPOGRAPHIC MAP
GRAPHIC SCALE
1" = 660'
1' D
The c". - Rance boundary Is establshed elther 250 Ft from the rssldua4s application area of 50 feet Wthin
In the property boundary, whktever Is closest to the applieallon area. The resew boundary Is established
midway between the compliance boundary and the peaifneeter of the residuals application area. AM
locations are appraisimate.
NC-CO-36
Field 1

TOPOGRAPHIC MAP
i
iii "J
— -lv_
GRAPHIC SCALE
IN=6601
The compliance boundary Is estabshed elftr 250 R from the residuals apphca5on area of 50 feet within
In the pmpaty boundary, whUmer Is dosest to the appl►raffon area The review boundary Is established
mid*ay between the compliance boundary and the *meter of the residuals application area. All
locations are approxbnate.
NC -CCU 36
Field 2

TOPOGRAPHIC MAP
o
N
f "
8
';lFBiIK ..
GRAPHIC SCALE
1 e = 66Y
The compliance boundary is established either 250 h from the residual appli aloe area of 50 feet within NC-CO-3
6
In the poprt}+ boundary, whichever Is closest to the application area The review boundary Is Established
midway between the oompliante boundary and the perimeter of the residuals aptrlicabon area. AD
krcalians am apprdxbnate, Field 3-5

_ g' tWj State of North Carolina
DW
� ^, Department of Environmental Quality
Division of Water Resources
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 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 Land Application Site Certification (FORM: LASC 06-16) form. Please
o 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.
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: 1V T U k
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (ie., 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)
NC cd 3
/�'
lea w o ops
�w
I �f;a ids
/ —Y 7 -T
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.
his Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
FORM: LOA 06-16 Page 1 of 3

1, STIPUATIONS:
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 sites) to a third party, the landowner shall
be responsible to ensure that the third party agrees and complies with the terms and conditions of this Agreement.
3. The landowner or his representative shall adhere to the provisions of this Agreement until all of the site restrictions (under Section II) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617
Mail Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the Iand 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.
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.inonths 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.
M. 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 .01051 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;
�Are-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: 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 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. 1 .. . J-
Landowner name: i! L
Address:,
City: {.`
Phone:
Signature: �-
NORTH CAROLINA,
I, the undersigned Notary Public do hereby certify thatGo
personally appeared before me this day and acknowledged the due execution of the forgoing insa G.
WITNESS my hand and official seal this the _ ra •• ��.:
s `1
day of _._ 220
Signature and seal:' f+ •
ME
My commission expires: C O �$ •' _
M
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/ol
Address:
City: =� State: Zip:
Phone: E-mail address:
Signature: Date:���
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: h % v� A rr S � h11r m
Signature: Date: _ ttl_zo_[ ( Q;
FORM: LOA 06-16 Page 3 of 3

•
C
1-1

VICINITY MAP
F 11
.!a
CcsZtcs
C
Brunswick
I N411 Go gle
GRAPHIC SCALE
1, = 8,000'
U00 a Blow
The compliance boundary Is established elthet 250 ft from the resIduals application area T 50 feet within
NC-CO-37
In the property boundary, whichever Is closest to the application area_ The review boundary Is established
midway between the complianc* boundary and the *rreter of the residuals apoication area. M
locations are approximate. Fields 1-4

JAME
s� _. ��iill���i./!/!//N///lliNlFr•�rrr:: ri -�i � _
• •.i i.lrlr.lr..J
rY.¢.

"--A- -# f ..

V
1 /4

rid
11
zt,

SOIL SURVEY
ti
-�'PA �'f'Y VgYVY'Y VYV YYO�VVvvt� '
■' a
T Ay ;
1
s •` T
� •.f ti '�
GRAPHIC SCALE
1" =1,000'
The cornpliarce boundary is established eltMr 250 ft from the residuals appocation area or 50 feet vdthin N C_CO-37
In the property boundary, whidwver Is closest to the application area The review boundary Is established
midway betveen the compliance boundary and the perimeter of the residuals application area. An
Iocabns ace approximate. Field 1

> SOIL SURVEY
too
r,
r�r 9 r
1* r
�r
-
r .�
t.
f � �
•y �; i
i
Y
GRAPHIC SCALE
i"=809
ana ac�
ililooilii
The cotrtplIaWA boundary is estabished +either 250 ft honr the residuals application area or,50 feet within N C-CCU-37
In the vopvV. boundary, whicheuet Is dosest to the applicelon area The review boundary Is established
midway between the compliance boundary and the perimeter of the residuals application area, AN
location are abproxhata. Field

SOIL. SURVEY
Y�
a
f
GRAPHIC SCALE
1"=1,000,
.oaxr a y,ao�r
The wmplince bouirdary Is estabhhed ellher 250 ft from the residuals application area of 50 feet Within N C'CO^37
I n the property boundary, whichever Is closest to the application area The review bourklary Is established
midway bettrreeen Me cormplianoa boundary and the patifWer of the residuals application area. AN
localIons ate appr Xhate, Field 3

0 SOIL SURVEY
ix
U
z
i, tit
GRAPHIC SCALE
1" = 809
The compliar" bourrdery Is estab1shed eltirer 250 st from the residuals appho4on area v 50 feet Wthin N C_CO-37
In the properCy boundary, whic Over Is closest to the application arm The rNeta boundary Is established
midway betvreen the compliance boundary and the petirmter of the residuals application area. All
locations are app.,oximate. Field 4

TOPOGRAPHIC MAP
6s A
q Aa A.AAa� ld'�
' $¢✓��"'vvv9-VVVG'w9 V'�t'-'�y.�Qpr- �tr-c;
b e v 4b
�'.R AIL
4 and
}��� { _
L_ "T4 a1 it {
Vv 1, d
i
.t 1
GRAPHIC SCALE
110 =1,000,
t r rr
The conpl ara boundary is estabishO eftr 250 ft from the msldLw s appGcanon area of 50 feet WithinNC—CO-37
in the property boundary, whiter Is chest to the application area. The to Aew boundary Is established
midway between the comptiaarm bouodafy and the perimeter of the reftals appl icatim area. M Field
I Cation5ate pror�imata. i'"ield

TOPOGRAPHIC MAP
Ct
+y,a
4 �
s�1
a
P 4 yp
GRAPHIC SCALE
1"=1,000`
t, a
The wmpllan boundaty is establlshed either 250 ft Port•, the residuals appfiaaiion area w 54 feet Wthin N C-CO-3 !
In the propefty boundary, whkAevv 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
locali m are approximate. Feld 2

ell
TOPOGRAPHIC MAP _.
�►'F5 Y 1A a1JI Oft
i
_S
L'V
7 � 6
r
GRAPHIC SCALE
LOW LOW,
The compliance boundary 15 established either 250 ft from the re81d►}at5 application area w 50 feet vdthin N C-CO-37
In the property boundary, whichever is closet to the application area The review boundary Is established
midway between the compliance boundary and the perimeter of the residuals application area. Ail
Io�cafims are approximate. Field 3

0 TOPOGRAPHIC IC MAP
�6
4
i
c.
�1�SLt
F a7t1�.4[T4
GRAPHIC c SCALE
1 " = 660'
�LfY D '
The compliame boundary is established either 250 It trwri the residuals application area or 50 feet within N C—CO-37
In the property boundary, whichever is closest to the application area,. The review boundary is established
midway between the compliance bowidary and the pdrreter of the residuals application area. A N —
locations are approximate. Field 4

$kddy Ayrd State of North Carolina
Department of Environmental Quality
Q�✓j Division of Water Resources
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 conies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Per-ynittina 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 i5A 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):
91, 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.
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:yUU —k,
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
Lease
(Y )
'Land Use or
Cropping Patterns
PP� g
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
^� 0 rZ
Rai' c ro..s
Mimal rcr
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.
is Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
-.,,iall 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

if. ' 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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 detemuning
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.
-A. RESTRICTIONS:
1. Appropriate measures must be taken by the Penuittee 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;
&ZA 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.
TV. 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 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 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 Perminee to land apply residuals to the land application site(s) as specified
herein.
Landowner mane:LJ pr �r! jr d _
Address: • 132 16
City: L Q Kc In a C C a m df, W state: --WC Zip: Q
Phone: � 1 O �}p , E- ail address:
Signatures Date:
TH CXROLINA, i €� nn y3 e._S —COUNTY
I, the undersigned Notary Public do hereby certify that AAeluFri initials: M 6 personally
appeared before me this day, and, being duly sworn, stated that in his/her presence �� ! signed
the attached document and acknowledged the due execution of the foregoing instrument.
WITNESS my hand and official seal this,�he day of je eJ-91" ff 20
Signature and seal: )
My commission expires: _
Lessee's/Operator's Certification:
I certify that I have read this A
Lessee/operator name:
Address:
City:
Phone:
Signature:
Permittee's Certification:
KUUERT N. ROM
NOTA DV '41V B c
GUlLFOR6 COUNTY
STATE OF NORTH CAROLINA
and do hereby agree to abide by the stipulations and restrictions as specified herein.
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: M% \ J A 1f1.r _
Signature: W,4� _V C___
Date: OIts
FORM: LOA 06-16 Page 3 of 3

0
0

0 VICINITY MAP
d
z
,3
—361 O�d jtr03i Rd
A
c
f
1
8,Aim wale R6
i E+li
i Q3fs
GRAPHIC SCALE
1° = 2,000'
1OW, 0 2,rk1Q'
The compliance boundary Is established eithef 250 !t from the residuals application area or 50 feet vdthin NC-CCU-60
in the property boodwy, whichever is closest to the application area. The rWew txwndary Is established
midway, between the compliance boundary and the perimeter of the residuals application area. All "
localioas are approximate. Fields
ields 1-7

APPLICATION MAP
LEGEND
APPLICATION AREA UNSUITABLE AREA
— — — — ®— yJATfR
PRIVATE RVAU
STREAM
■
n
-- — DRAIN
--- FENCE
PROPERTYLINE
ONStTE HOUSE
OFFSITE HOUSE
OUTBUILDING
WELL
The txnrbpllaw boor&q 15 estat hed either 250 It from the resldua6 apptitatton area o€ 50 feet Wtmn
In the pmpeEiy boundary, wh�c mer Is dosed to the applitetion area_ The Wew boundary is estabished
midway between the compliame boundary and the *meter of the residuals application area. AN
Iooaltons are ayproxoata.
GRAPHIC SCALE
1' = 66V
f e
NC-CO-60
Fields 1-3

APPLICATION MAP
tn
- ` J ' .'.
`lril
I ¢
i
w �
LEGEND
APPLICATION AREA UNSLI1ITABLEAREA
— PRIVATE ROAD ` w WATER GRAPHIC SCALE
---a — — --- STREAM ONSITE HOUSE V = 66V
—� - DRAIN OFFsTE HOt.ISE
FENCE u Ot.ITl3ulwiNG
--- PROPERTY LINE 0 WELL
The coriViiara bour4ary is established either 250 h from the residuals applWOon Area os 501eet Wthin NC—CO-6V
In the property boundary, whichever is slowest to the application Area i he renew boundary is established
midway between the compliance boEmdary and the *meter of ttae residuals aplicalkn area.. M
1®ca60ns are apptioxinate. Fields 4-7

0 SOIL SURVEY
cr
)
Q
}
y_
F '
/ L
. i
i •f
S-
GRAPHIC SCALE
1"=8W
89[l` 4
l '
The oornp[Wal boundary is estahished egher 250 ft from the residuats appRe8lon area Ot 50 feet within N C-CO-60
In the pmpezty Windary, whichever Is dosest to the application arm The review bour&y Is astabdshed
midway between the com, purl boundary and the ped meter of the residuals application area.. M
Iwatioraare approWate. Fields 5-7

TOPOGRAPHIC MAP
GFWPHIC SCALE
in = 800'
ear a eaa
Tit comptance bouralary Is establlshed epher M ft from the residuals application area or 50 feet within N C-CO-60
In the Me;tyy boundary, whomever Is closest to the appliratton area. The review boundary is established
midway between the compliance boundary and the *meter of the residuals application area. Ail
locations are approximate, Fields -

TOPOGRAPHIC MAP
z,�
�a -
a J
b
Mir ,
GRAPHIC SCALE
1" = 800'
4
The r pliara boundary Is established either 250 It from the residuals application area rr 50 feet within N C_Cq_60
In the property boundary, whidwer Is dosest to the application area. The review boundary Is established
midway between the compliance boundary and the perimeter of the re-,siduals application area. All ,
locations are approximate. f C elds 4-7

Bobby No0rc
Co-6o
Division of Water Resources
State of North Carolina
Department of Environmental Quality
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 cokes of the application and
su a portint* documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Permittin_, 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 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.
Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
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: 0.�' � - - . - . _ -
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:
Lease Land Use or Residuals Source Special note
Site/Field ID [(yes/no) Cropping Patterns Intended Use of Crops ioptional) (no-till/over-seed/
pasture)
NC-�Gr"
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.
its 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

T. ' STIPUIL ATIONS:
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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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.
11. RESTRICTIONS:
1. Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public access to the land
application 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� hl 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;
E�—A re -defined compliance boundary is needed for field(s) ID: LQ -- ( o / 5,
(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:._ _ _ _ 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 ofthe 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 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: O P R. C7 a �
Address: 16Y 1.;Vigisro N
city: D a / c 0
ch,c, ac l Road
State: KC zip: S� _--
Phone: 1 & - _ 170 Woo E-mail address:
Signature:' 1
NORTH CAROLINA, COUNTY
Date: 9 — " 2 0 I
I, the undersigned Notary Public do hereby certify that _ && n 6 n CU21— (initials:A46) personally
appeared before me this day, and, being duly sworn, stated that in his/her presence & i� _P400 M` signed
the attached document and acknowledged the due execution of the foregoing instrument.
WITNESS my hand and o�cV seal thisAle day of D � 20 Lq
Signature and seal: inky
My commission expires: f9 7W�T7OBEN. ROTH
PU1
FORM: LOAA 090814 Page 2 of4 GUILFORD COUNTY"ehment. rder 3+c
STATE OF NORTH CAROLINA
Lessee's/Operator's Certification:
I certify that I have read this reement and do hireby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name:
Address: Voa-
City: �� - State: [ zip:
Phone: OR ( E-mail address: / p
Signature: Date:
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: \_N 1 � Y►
Signature: fyV • — Date: 1%boo I 1 Q
FORM: LOA 06-16 Page 3 of 3

0
0
0

0 VICINITY MAP
{r
%r
Q
1e Johns Branch
t835 b 3
pYP
?J
Q
won
1843
E a
�tr
k�
9
pintiy frte Ad
GRAPHIC SCALE
A
le = 1,iiW
The compuan boundary Is estabished elther 250 (t from the residuals application area o: 50 feet within
IBC -CO -fit
In the property boundary, who mover Is closest to the application area_ The reuiew boundary Is estabished
midway between the comp(ianoe boundary and the pedrreter of the residuals application area, M
locations
Fields A _3
are appmAmate,
1

APPLICATION MAP
LEGEND
APPLICATION AREA UNSUITABLE AREA
s — — — — - PRIVATE ROAD WATER
GRAPHIC SCALE
STREAM ONsl1 E HOUSE
1" = 66V
tea°
- A — DRAIN OFFSITE HOUSE
o
-Pf X : - FENCE n OUTBUILDING
PROPERTY LINE 0 WELL
The co erpllance boundary Is estabshed ellher 250 ft from the residuals application area nr 50 feat within
NC-CO-6
In the property bomdary, whichever Is Closest to the application area The review boundary Is established
midway between Pie comoiance boundary and the perimeter of the residuals applitatiori area. AN
►oatiorts are approXhate.
Fields 1-3

]
SOIL SURVEY_
y i
r
41
•
Y�
GRAPHIC SCALE
lit = S�lll,
ssn a 6M
The Banco boundary Is established o thOr 250 It from ft residuals application area o� 50 feet within
N C-CO-61
in the property boundary, whictwor Is dosest to the apfftolon area The re0ew bouundary Is established
midway between the compWm* boundary and the perimeter of the residuals appliretinn ama. AN
Ie.Gtu� are oppmxhate.
Fields 1 R3

r�1
TOPOGRAPHIC MAP
GRAPHIC SCALE
V ; 6G0"
OW
The wqlWa boundary is estab aped+ 11W 250 ft from the residuals appGcabon area x 50 feet within N C-CCU-61
In the property boundary, whichever Is closest to the appuzallon area,_ The.reilew boundary Is estabdshed
midway between the compliance boundary and the perimeter of the residuals application area.. Al .f
l©cations are approximate. Fields ['3

State of North Carolina
Department of Environmental Quality
Division of Water Resources
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 notes), the Applicant shall submit one original and two copies of the application and
sunnortin, documentation
For more information, visit the Water Quality Permitting Section's Non-Discharae Permittin,; 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. L nd Owner Agreement (FORM: LOA 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.
Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
19, 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) (Le., 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)
If rf
P ' A re
Affi, or reed
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.
is Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
;all 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

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 II) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617
Mail Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the Iand 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
. 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
HLALTERNATIVES 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(hallows 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)
,LA 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 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

0 VICINITY MAP
Mgp
Q
z
n� tit
A.4or
� i J
4a, ti
V
.iR
^ ,a
rw
.r"
GRAPHIC SCALE
I" = 4,000'
'UM. 0 OW
The compliance boundary Is established either 250 fc from the resilduais application area or CO— I 64
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 applicatlon area. All locations are approximate. Fields f ,2A5,8,9J 3- i s

rAw
AL

y .
f
• ✓
LEGEND
APPulICFTION AREA WATER
_ _ _ v ; }„ ac�c ■ ONSITE HOUSE GRAPHIC SCALE
STWEA1 OFF -SITE HOUSE
-- s DRAIN OUTBUILDING
PROKRTY LINE WELL
The =wanw bwrAWY is a fished either 250 8 Irm the residuals appicabon area cy 50 feet 'Oft I CO-164
In the pmperty bowolmy; whichever is closest to the appao6on area. The resew boundary is esMshed
Wdway betareen ire eornptian;e bowidary and the perimeter of the residuals application area. M
lotgonsate axmxynate• Fields 2,4,5,8,9

APPLICATION MAP
z
V)
. 1� • 4 - p-r�Lu 'i
� r
LEGEND
t4P' ICAT I AREA WATER
PRIVATE ROAD 0N9TE 14OUSf;
GRAPHIC SCALE
STREW OFFSITE HOUSE
OUTI ILDING a dso
_... � I�IIAIN L� 1
PROPERTY UNE 0 WELL
The compliance boundary is established either 250 ftirorn the residuals application area or CO- 164
50 feetwithin in the properly boundary, whichever is closest to the application arcs. The
review boundary is establisher, midway between the compliance boundary and the
perimeter of the residuals application area. All locations am approximate. Fields 13 ^ IS

GRAPHIC SCALE
III_'
soot a •
The "lance boundary Is est shed antes" 250 tt ftm the residuak aplicabon area or 50 feet within
I n the property, boundary, wbdmm Is doses# to 6t aWcation area- W Wes bmvdary Is estabished
midway twetween the tnpriance boundW WO to perimeter of the residuals applicabm area. At
loess are app<'oximata.
CO-1 64
Fields 2,4,5,9

Sall SURVEY
? f
:_01 ki
- s F
• r
w rr
r
t
Y
^..
GRAPHIC SCALE
1"=rag
SOY a SW
The cuoVIIatxe boundary fi estabyshed neither 250 tt from the residuals application area Or 50 feet Wthin CO-164
I n the pmpedy boundary, whichevcf Is dosest to the application area The review boundary Is estabrished
midway between the comoience boundary and the petimter of the residuals appl ication area, AMI I tt
1001fi s are appfoxintate• Fields 2,4,5,9

0 TOPOGRAPHIC MAP
4!�A�'�a41" �
tQ>
44
vi
GRAPHIC SCALE
1, = 1000'
The w"lime boundary Is established elther250 ft(mm the residuals application area of 50 feet w1thin CO-164
in the property boundary, whichever Is dosett to the applicagon are'& The YeAm boundary Is established
midway between the compliance boundary and the perimeter of the residuals application area. All
hiss a Fields 1,2,4,5,8,9

TOPOGRAPHIC MAP
it
Oy j
�2$f SSA
t" O vvr►ae�Aa�
YYV "
aA
YY 3� b a�V'Q'Pi✓ �✓
e.�• a n.e�n A w ..... r. n�
V
r � � o-P904YYQYYp-p-p
- a�anaeQ
6VVPpYyprVyT 7'PV'-�'Yy.p���.
PYVV 9 vp .ge14.�
91.
�, 3t
t
t �[
r
AlAXI W-* 4' rip w
GRAPHIC SCALE
I " = 1 QOW
low 6 iow
I
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 13 , 15

M r'XlState of North Carolina
it,Department of Environmental Quality
Division of Water Resources
kft`.-.
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 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 1 5 A NCAC 02 T .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. <So
Owner Agreement (FORM: LOA 06-16):
ubmit thecompleted and appropriately executed Land Application Site Certification (FORM: LASC 06-I6) form. Please
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.
KPrepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
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:
y
Applicant's name: —L (-k^ - — - - - - - - - - - - -
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (Le., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Site/Field ID Lease Land Use or Intended Use of Crops
(yes/no) Cropping Patterns
no io
H0 rune as p� t/ jtfet 1 Feed
Nay -- -- ----
Residuals Source Special note
(optional) (no-tiil/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.
his 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 of cancels this Agreement.

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 I) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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.
A. 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 fallowing 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.
M.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 .0105th) 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;
$QA 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: . is currently permitted under another
residuals land application program; Permit Number WQ: The Iand 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 ofthe new program)
Tf1TA If. i A A Af i f n....w •i .��'Z

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:
Address: AL 7 SoI C S
City: State:. !7 C - -Zip: oZ 6 t72
� — -
Phone: _q1 O r/7 T, 3 Y t2 q E-mail address:
Signature: cant—_ _ T _ Date:
NORTH CAROLINA, i c�9 COUNTY
I, the undersigned Notary Public do hereby certify that /" 9 6- 6 Dad. (initials 6 ) personally
appeared before me this day, and, being duly sworn, stated that in his/her presence rjivket S `p Z�L signed
the attached document and acknowledged the due execution of the foregoing instrument. q
'WITNESS my hand and o[I"cial seal this the day of C)e_�-ob & 120 11
Signature and seal:
My commission expires: Vie., 4r—ZAJ' ROBERT N. ROTH �T
NO ARY PUBLIC
GUILFORD COUNTY
srArff OF,vURrx CAROLINA
Lessee's/Operator's Certification:
I certify that I have read thi"greement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lesseefopernatorrnname: _
Address: N d SOLESa
City:/ ✓/« E State:
Phonqq c3 e: _� /gg,,/ T E-mail address:
Signature: _ oi? .
Permittee's Certification:
Zip: •���`%Z
Date:--o?D��
I certify that I have read this Agreement and doherebyagree to abide by the stipulations and restrictions as specified herein.
Signing official name: �_- V A Y7 Signature: % Date:—' 16-ti 1�
TY-MAX. T!1A AC 1L U.n— S ofI

State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
Division of Wafter Resources 15A NCAC 02T .I100 — 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 orjgival and two copies of the of L)h ation and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non -Discharge Perin ittin.. 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 i5A NCAC 02T .1 M. 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 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.
]- 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) (ie., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Lease Land Use or Residuals Source
Special note
Site/Field ID (yes/no) Cropping Patterns Intended Use of Crops (optional) (no-till/over-seed/
pasture)
' NI S
1.5. cb.R WayjPc, sFoc AWtr► ,a i f�-,ced
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.
.his 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.
-/ -i - 4 .-.. nI i i pave 1 of l

+.
r
I STIPULATIONS: �, r
I. 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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.
1I. 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 Iand 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.
M.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: U--
(Please include the rationale for the requested re -location of the compliance
compliance boundary to the application package)
❑ A re -defined compliance boundary is not needed for this site.
IV. ACKNOWLEDGEMENT OF FIELD TRANSFER: (if needed)
and attach a map showing the newly proposed
❑ The land application field(s) ID: . is currently permitted under another
residuals Iand 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)
rfNnrT. rye nt Yc 'D,--I _1PI

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: UD AN ar % a s
Address: _ l_ n S4 VS RO Ri► •
City: • w yp; tie e State: A-14 _ Zip: Y V -
Phone: E-mail address:
Signature: _ Date:
NORTH CAROLINA, �0 } , COUNTY
I, the undersigned Notary Public do hereby certify that c 1U �n ��0 (initials A16) personally
appeared before me this day, and, being duly sworn, stated that in his/her presence lO 5kjaoey signed
the attached document and acknowledged the due execution of the foregoing instrument.
WITNESS my hand and o rival seal this the ij—, day of20
Signature and seal:
My commission expires:
Lessee's/Operator's Certification:
NOTARY PUBLIC
GUILFORD COUNTY
STATE OF NORTH CAROLINA
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: _S-A9 1W 6-
Address:
City:
Phone:
Signature:
Permittee's Certification:
State:
E-mail address:
Date:
Zip:
I certify that I have read this Agreement and do he�rejby agree to abide by the stipulations and restrictions as specified herein.
Signing official name: M\ `C V
Signature: CNN Wa �fh� Date: %%laoll9
—l—. —T—a nI �!

LEGEND
AWLMTION AM VIA t1N&RAME Awl
_ _ PRIVATE ROAD `�*� � � WAiER
STREAM w
El
0
ORAN
FENCE
PROPERTY LINE
CI'"TE HOUSE
©lYMILDiNG
WELL
The cofthum Muldary Is estabWWd either 250 ft from the fesaduals applesSon arm or 50t+eet vrit*
in the Wooeeq may= whictmer Is closest to the applicalw areiaL ThereviewbwWWleasWished
mbny bamew the =oiaroe boundary and the perimeter of the residuals apoicetim area. AN
iocati n ate appo Ximate,
GRAPHIC SCALE
- 66V
95ff 0 W
SIC-NH-02
Fields 3,4,10

APPLICATION MAP
Z
{-
LEGEND
AkMUCATION AREA � 'ABLE AR, V%
PFWATE ROAD C W .7 WA7ER
GRAPHIC SCALE
--. — - -•�-� STD ■ Own Mm
1" - 6W
iE$0'
I7MN . tFF$ITIENO?;;E ;�■��
© ii;f3
mNm OUMILDING
PROPERTY UNE 0 WEU
The emolance bomi&y Is estabfrshed either 250 ft from the residuals sWcdon area of 54 feet Wt*
NC-N H-02
In the pmpefty boundmy, whichever Is dosest to the Wficalon area'_ The teview bomdW Is esMshed
rW&xay between ft cmioianx boundary and the Wmeter of the residuals *Okation area. AD
I dons ate a xivale.
Fields 9A&B

APPLICATION MAP
T:R�L'i■,'
APPLICATIONAREA UNSUITABLEAREA
SIMM ONSITE HOUSE
- -- _ DRAIN OFFSITE HOUSE
FENCE Q wtBuILDING
PROPERTYLINE 0 WELL
The emplaom boar4my Is estabMaNd eldvt 250 ft km the ►ester appucapon area at 50 f wkhin
In the p ty bwndxy, whtlow Is dosest b ft applIcOm area_ The molewr bowydw is estaW'AW
ddM%ermwn Me cwWknw boundary and the pedometer of the reftels application area. Al
locadom are approximate,
It
GRAPHIC SCALE
era a s-s.,
t
NC-NH-02
Fields 10

APPLICATION MAP
Ix
AA! WV��
0�
4.
N
Yii 3 ty C
LEGEND
APPM7ItN AREA ® UNWTAKEAREA
MAX ROW WATER GRAPHIC SCALE
«�«
t m OFFS 7E NI E
-- PROPERTY LICE 0 WELL
The wNliano bud" is esWsW edw 250 ft from the residuals oppGcobon area or 50 feet * t><4h NC-N H-02
i n ft pry tsmxwy= wtiidt is d seSt to the aprsati m area_ Theroviewbo wx1wy1sesbbkshod
vidway 6etwom ftre fiortMti ow 1xviday and the perimeter of the residuals applioalm Dies M
laoatio, atea*oxitoate. Fields 11A&B

0 SOIL SURVEY
z
V)
GRAPHIC SCALE
Thewoob
� v t,00a
,F
w bwnfty Is egabk,*od eVw 250 ft tt residws amboolon aru ot 50 W %IUn NC-NH-02
1 n the pricey boratct�yw �+� rs dil5�t (� tFia u��an �e�� eeaicw lxwnda�+rs est�shed
midway b&'*vm the wee tourdary and the *meter of the residuals applicalbn wa& M
l are aWoxknate. Fields 3,4,6,10,11

TOPOGRAPHIC MAP
st
4�_ _
-- ahs:w.�n4-d�aclA.Jnaiw�
0
GRAPHIC SCALE
V `^ tow
t,0�S1 0 �V� Im
f
IBC-NH-02
Fields 1,2,8,9

0
TOPOGRAPHIC MAP
Z
prince �}
.�rYPpP
�
i
A
1
rj
� LV, /
L E
GRAPHIC SCALE
V = tow
Low
The mvUnm boundary is estobfisW ether 250 tt [roar th* m1duals a0coilion arm of 50 felt Ott
in the property boundary, %vbd*ver is dosest b the application area_ The mview bwWW is estabashod
NC-1 Y H-V2
midway between the cw#iance boundary and the Wmeter at the residuals VoicaWn area, M
locations" approximate.
Fields 3,4,6,10111

VICINITY MAC'
I
i
a
&�Ilh�amihon racl
to
r
t
GRAPHIC SCALE
V _ 4,000t
7 UW OW
The bouW y is esWbMsWd aftr 250 !t Wn the residuals aplicafion area or 50 (het %itiin v 'N �l �UL
In the property boundary. wfi i+er Is closest b the aprplicalm area. The review hourAmy Is astabiished
midway between the cmViance boundary and the Wmeter of the residuals appl katbn area. A
locations ft tqnxknate. Field 1-4,6,8-11

Q ­DWR
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — LAND OWNER AGREEMENT
FORM: LOA 06-16
PIease 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 notes 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-Dischaige 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 i 5 A 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):
06 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.
Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
FApplicant.
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: e r P. Ck
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 ID
i �j
e 'HIV �7 - 02 --
6CId
141-»*A
Lease
(yes/no)
Land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
No
Fe.ej
iF'i e 145
9•8 10/��
�lQ
t`N�` reps
Plat i. MbF
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.
its Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
wall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
FORM: LOA 06-16 Page 1 of 3

1. 'STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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 Tune 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.
.t. 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.
M.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 .01053h1 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)
RA 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 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 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.
v Landowner name: _j2iy;4 _Q, _Fo l-7
� 1 Address: DG-✓% Si --
City : : OjG K- ivcf State: S C- zip: ' 2 y,_ _ 4 L _
Phone: �1 icy ,$- to - -7?2?--7 E-mail address: Aw✓i d- 5- +4✓� 6v
Signature: r iw. Date: l c7 �O /
NORTH CAROLINA, 0t COUNTY
I, the undersigned Notary Public do hereby certify that A'7 LC I initials: personally
appeared before me this day, and, being duly sworn, stated that in his/her presence rot 'S . (-Tl- signed
the attached document and acknowledged the due execution of the foregoing instrument.
WITNESS my hand and official seal this the �Q day of obi 20 i
Signature and seal: Tyl
My commission expires:
4 Lessee's/Operator's Certification:
NOTARY PUBLIC
GtltLFORD COUNTY
STATE OF NORTH CAROLINA
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: i, 4
Address:
City: &Z/'I.t ."n.ra.t�
Zip:
Phone: U ` 02 �i E-mail address:
Signature: Date:
Permittee's Certification:
State: l
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: N ►\N Di_►- s Vann
Signature: � s, - - Date: 11 jj,�
FORM: LOA 06-16 Page 3 of 3

'-L
VICINITY MAP
S'.
y'�ea
GRAPHIC SCALE
I" = 2,000'
2,000' 0 2,000'
. --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.
NH-03
Fields I - 4

5#1
"D
Ln
APPLICATION MAP
LEGEND
APPLICATION AREA
PRIVATE ROAD O
STREAM
DRAIN ■
x x x FENCE ❑
PROPERTY LINE (X
r-
UNSUITABLE AREA
WATER
ONSITE HOUSE
OFFSITE HOUSE
OUTBUILDING
WELL
i'he 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'
Fields I - 4

TOPOGRAPHIC MAP
r
GRAPHIC SCALE
I,, = 1,000,
11000, 0 1,000'
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 H-03
Fields I - 4

To

_link State of North Carolina
MB �� Department of Environmental Quality
/ Division of Water Resources
Division of Water Resources 15A NCAC 02T A100 —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 Pernaittin, 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 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.
Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other, than. the
Applicant
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
fhe undersigned landowneror his representative hereby permits:
Applicant's name: _-- C 1.r V � b
f
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
application site(s) (Le., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Sitetiield ID
Lease
(yestno)
Land Use or
Cropping Patterns
Intended Use of Crops
-
Residuals Source
(optional)
Special note
(no-tiWover-seedt
pasture)
c-Nei-o„
tv
c r0P
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.
tits Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
,all 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 }n advance, modifies of cancels this Agreement.
FORM: LOA 06-16 Pagel of 3

L ' 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 partN 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, 1617
Mail Service Center, Raleigh, NC 27699-1617.
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 Pehnittee.
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 ofthe 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
time 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 (eg., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative will inform the Petmittee 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, Iocal 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 temps 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.
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 ianctapplication site(s).
2. Animals shall not be grazed on the land application site(s) for a 30-day period fallowing a residuals land application event Land application
sites that are to be used for grazing shall have fencing that will be used to prevent access during these periods after such residuals Iand
application events.
3. Food crops, feed crops, and fiber crops shall not be harvested for a 30-day period following a residuals laud application event
4. Food crops with harvested parts that touch the residualstsoi7 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 shah 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.
M. 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)
MA re -defined compliance boundary is not needed for this site.
W. 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 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 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: C.A Y.1 s %� K. 11a e- � --
Address. _ _ / b f C o�l� Cl✓�
City: NGW (0r2fC G tTY State: 1�1C�U %1 IP/C Zip: !00 Z
Phone: q ILI, 7 %' 6 3 E-mail address: G kmq_ok Max— e aY> R--
Signature: J7—Date: Z
F
NORTH CAROLIN RA-t v &4A-10- Z COUNTY
I, the undersigned Notary Public do hereby certify that ,P i T
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the 110
day
Signature and seal:
My commission expires: _j� —1 y- Z 010
tm
Z U
--
Lessee's/Operator's Certification:
I certify that I have read this Agreement and do hereby agree to abide by the ons and as as specified herein.
Lessee/operator name: / G t� �i }Li✓ 884 N°
Address:
City: �v / �J{.4 i Stater Phone: Y__)e) G Yi E-mail address: A? i' f0" Ag` r.L
Signature: ' - _ Date: 5 /
Permittee's Certification:
I certify that I have read this and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name:
SIgnature: P!�k r_,�j — --�
Date: 1 t
FORM: LOA 06-16 Page 3 of 3

wo
,lr

�'�•, ,✓fir .:fN:• .,�:- ... •... - r f::
j' //.err//>r`�i1/f///�' -"i' f r :::.., f::'-;.fit• , ;
f e
01.
-'i ....1. • %fly
riff � +y Fes..
�f � if fr Y1� �W4429
! f�� r,
PlJ,1,•i.•;,�%-ii �� %frf " .. ', i r. . ; Via'.. f_� ,f 6::

F ` '-" .•�`�f���F�rffJ%Yf. _ff 'f'•`rs 'r�� ����frf�'���00,

SOIL SURVEY
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.
NC-PE-03
Fields 1-3

SOIL SURVEY
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
NC-PE-03
Fields 9-1 2
locations are approximate.

t
Y:7
TOPOGRAPHIC MAP
rt
L1
F
i
R
r
A
,1
�i
GRAPHIC SCALE
V=1,000'
1,000- 0 1,000,
The compliance boundary is established either 250 ft from the residuals application area or 50 feet within N C-P E-03
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 9-12

1%
- -: P�der High Schdo! _±
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.
NC-PE-03
Fields 1-12

" 'R
DW"
Division of Water Resources
r a Al �, � �' ��.. State of North Carolina
DepartmOit of Environmental Quality
P11F''' 0-9 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 orWpal and two conies of the application and
supporting documentation
For more information, visit the Water Quality Permitting Section's Non-DischcarQe Permitting Urait.
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class S residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 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 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.
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: (-1-77 V
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-seedl
pasture)
tic s -* 0 3
l i/ ®
fd.s
9 lop
if a-y 146.9 r4
wt M 1 Fro
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.
his 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

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 H) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWI, Non -Discharge Permitting Unit, 1617
Mail Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the Iand 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 sites) 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.
,I. 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 Iand 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.
M. 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 .0105i 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;
re mdefined compliance boundary is needed for field(s) ID: E- L` _
(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.
W. 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 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 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 laud apply residuals to the land application site(s) as specified
herein. _ .,
Landowner name: i JA/Lar` V, r d
Address: („% Q Q S
City:, U r State: At. C e Zip:
Phone: E-mail address: G. Al d- h Is/ OCT. Al
Signature: • �' O (,'�
Date: _
NORTH CAROLINA,COUNTY
I, the undersigned Notary Public do hereby certify that WAWA O initials: personally
appeared before me this day, and, being duly sworn, stated that in his/her presence T -Vo!1 signed
l the attached document and acknowledged the due execution of the foregoing instrument.
/ WITNESS my hand and o tcial seal this the day of �C7� 20
Signature and seal:
r
My commission expires: OV ��� -7D vi nnn�r.•r �, �__..
Lessee's/Operator's Certification:
NOTARY PUBLIC
GUILFORD COUNTY
STATE OF NORTH CAROLINA
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Le"gee/operator name: (JL ifs Al Q, �✓ i Q_ i`
Acic ss: $ 7 A/ I�/ o ®c!SOLo
City., lA, I,/ State: r G , - —� -- — —
Zip: --
Phone: E-mail address:
gna �. d
Si lure: ✓ d . Date: 19
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: M\ V A
Signature: ���V �� Date:
FORM: LOA 06-16
Page 3 of 3

Q N� State of North Carolina
pe2 Department of Environmental Quality
DWR.,J Division of Water Resources
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
supportini-, documentation
For more information, visit the Water Quality Permitting Section's Noa-Discharae Permittin4 Unit.
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class S residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 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. L d Owner Agreement (FORM: LOA 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.
Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
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 landojlyner or his representative hereby permits:
Applicant's name:. (A
hereinafter referred to as the Permittee, to land apply residuals from the following facnity(ies) onto the following land
application site(s) (ie., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Site/Field ID
Lease
es/no
(Y )
Land Use or
Cropping Patterns
PP g
Intended Use of Crops
Residuals Source
o tional
(optional)
Special note h
(no-till/over-seed/
pasture)
At sw
O
-
t<2
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.
its 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

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 In are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR, Non -Discharge Permitting Unit, 1617
Mail Service Center, Raleigh, NC 27699-1617.
5. The Permittee must request and obtain a permit modification from the Division prior to a transfer of the Iand 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 Tune 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.
_i. 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 .0105rh) 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: _ l 1 T 3 v
(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: 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 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. 1
Landowner name: fM t e- r 13Y (W r'd A" Q N e— f'
Address: - 01 D 71 1 r/e-y W o D c�S 1 "t 6
Cit;�; il, i 91 Q j„% State: /V o Zip:
Rq
Phone: _"- q % - q E-mail address:
Signature: _ Date:
NORTH CAROLINA, I a �� COUNTY
I, the undersigned Notary Public do hereby certify that —Miluf^ Load (initialsW[4) personally
appeared before me this day, and, being duly sworn, stated that in his/her presence b• ?4y-iu1 G�+n��t%° signed
the attached document and acknowledged the due execution of the foregoing instrument.
WITNESS my hand and official seal this the
Signature and seal:
My commission expires:
Lessee's/Operator's Certification:
e�
day of ° 20
--ROgEFff—rv: R0TK—
NOTARY PUBLIC
GUILFORD COUNTY
STATE OF NORTH CAROLINA
I certify that I have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
t
Lessee/operator name: ,7 • LL 1-D A✓ h— Q Ar
Address: d q I ) P"I/y" 1,10645_ J l b &,A,
'City:. a V'r 0a,1✓/� State: i C1
Zip: J
Phone: TO— o XS E-mail address:6. r' e. r G.ft . /✓et
Signature: 6�6� Lm�
Permittee's Certification:
Date: 16 — ®) — �,d l
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: 5 YAK
Signature: _ _ _ 6. Ve,—
Date: 1,90115
FORM: LOA 06-16 Page 3 of 3