WQ0003281_Renewal Application_20201231

Initial Review
Reviewer
Thornburg, Nathaniel
Is this submittal an application? (Excluding additional
information.)*
r Yes r No
Permit Number (IR)*
WQ0003281
Applicant/Permittee
City of Belmont
Applicant/Permittee Address
PO Box431 Belmont, NC 28012
Is the owner in BIMS? r Yes r No
Is the facility in BIMS? r Yes r No
Owner Type
Municipal
Facility Name
City of Belmont RLAP
County
Gaston
Fee Category Minor
Fee Amount $0
Is this a complete
application?*
r Yes r No
Complete App Date 12/31/2020
Signature Authority
Signature Authority Title
Signature Authority Email
Document Type (if non -application)
Email Notifications
Does this need review bythe hydrogeologist?* r Yes r No
Regional Office
CO Reviewer
Admin Reviewer
Below list any additional email address that need notification about a new project.
Email Address
Comments to be added to email notfication
Comments for Kendall
Comments for RO

Comments for Reviewer
Comments for Applicant

Submittal Form
Project Contact Information
Rease provide information on the person to be contacted by NDB Staff
Name * Zach Key
Email Address*
[e-mail]
electronic subntttal, confirmation of receipt, and other correspondence.
Project Information
........ .....................................................................................................................................................
Application/Document Type* r New (Fee Req ui red)
r Modification - Major (Fee Required)
r Renewal with Major Modification (Fee
Required)
r Annual Report
r Additional Information
r Other
Phone Number*
3369577871
O Modification - Minor
G Renewal
C GW-59, NDMR, NDMLR, NDAR-1,
NDAR-2
r Residual Annual Report
r Change of Ownership
We no longer accept these monitoring reports through this portal. Please click on the link below and it will take you to the correct form.
https://edocs.deq.nc.gov/Forms/NonDischarge_Monitoring_Report
Permit Type:* r Wastewater Irrigation r High -Rate Infiltration
r Other Wastewater r Reclaimed Water
r Closed -Loop Recycle r Residuals
r Single -Family Residence Wastewater r Other
Irrigation
Permit Number:* WQ0003281
Ras Current Existing perrrit number
Applicant/Permittee * City of Belmont
Applicant/Permittee Address* PO Box431 Belmont, NC 28012
Facility Name * City of Belmont RLAP
Please provide comments/notes on your current submittal below.
US Biosolids, Inc. is assisting the City of Belmont, NC in preparing this renewal package for
its land application of residuals on Permit No. WQ0003281 from the Wastewater Treatment
Plant.
There have been no changes in the process or the way the residuals are handled since the
last issuance of permit WQ0003281. There have also been no changes in fields, nor buffers
since the last issuance of the permit.
Your attention in the review of this permit renewal application is greatly appreciated. Please
contact me with any questions or concerns at [e-mail] or at 336-957-7871.
At this time, paper copies are no longer required. If you have any questions about what is required, please contact Nathaniel Thornburg
at [e-mail].
Please attach all information required or requested for this submittal to be reviewed here.*
(Application Form Engineering Rans, Specifications, Calculations, Etc.)
2021 Permit Renewal.pdf 2.29MB
Upload only 1 PCF docurrent (less than 250 M3). Maniple docurrents must be combined into one RDF file unless file is larger than
upload limit.
* P By checking this box, I acknowledge that I understand the application will not be
accepted for pre -review until the fee (if required) has been received by the Non -
Discharge Branch. Application fees must be submitted by check or money order
and made payable to the North Carolina Department of Environmental Quality
(NCDEQ). I also confirm that the uploaded document is a single PDF with all parts
of the application in correct order (as specified by the application).
Mail payment to:
NCDEQ — Division of Water Resources
Attn: Non -Discharge Branch

1617 Mail Service Center
Raleigh, NC 27699-1617
Signature *
CAW
Submission Date Is filled inautorraticallyonce subnitted.

PO Box 146 Ronda, NC 28670
336-777-6909
www.usbiosolids.com
Tuesday, December 29, 2020
North Carolina Department of Environmental Quality
Division of Water Resources
Water Quality Permitting Section
Non -Discharge Permitting Unit
512 N. Salisbury Street
Raleigh, NC 27064
Reference: City of Belmont
Wastewater Treatment Plant
Permit Renewal
WQ0003281
US Biosolids, Inc. is assisting the City of Belmont, NC in preparing this renewal package for its land
application of residuals on Permit No. WQ0003281 from the Wastewater Treatment Plant.
There have been no changes in the process or the way the residuals are handled since the last issuance
of permit WQ0003281. There have also been no changes in fields, nor buffers since the last issuance of
the permit.
Your attention in the review of this permit renewal application is greatly appreciated. Please contact me
with any questions or concerns at [e-mail] or at 336-957-7871.
Sincerely,
3-ItA ­-�
Zach Key
US Biosolids, Inc.

State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
DNIslon 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 conies of the apolication and
sunnortina 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 .1 100.
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Residuals Land Application Program (FORM: RLAP 06-16) Application: (All Application Packages):
❑ Submit the completed and appropriately executed Residuals Land Application Program (FORM: RLAP 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments to
the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
❑ The Applicant's Certification on Page 5 of this form shall be signed in accordance with 15A NCAC 02T .0I06(b). An alternate
person may be designated as the signing official if a delegation letter is provided from a person who meets the criteria in 15A
NCAC 02T .0106(b).
❑ if this project is for a modification of an existing permit, submit one copy of the existing permit.
❑ Please submit this application form at 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).
Facility Classification New Permit Major Modification'
Major (land are permitted for > 300 acres) $1,310 $395
Minor (land are permitted for < 300 acres) $810 $245
' - 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)
❑ List all items included in the application package, as well as a brief description of the requested permitting action.
D. Environmental Assessments (May be Required — See 15A NCAC 1 C .0300)
❑ Submit a copy of the Findings of No Significant Impact (FONSI) or Environmental Impact Statement (EIS). Also, include
information on any mitigating factor(s) from the Environmental Assessment (EA) that impact the construction of the residuals
treatment and storage facilities. An EA may also be required for private systems if any public funds and/or lands are used for
the construction of the subject facilities.
INSTRUCTIONS FOR FORM: RLAP 06-16 Page l of 3

E. Operation and Maintenance Plan (New and Renewal Application Packages)
❑ For Modification Application, if there are any changes to the existing plan, submit an updated O&M plan.
❑ Submit the O&M Plan in accordance with 15A NCAC 02T.] 110 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.
❑ 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
J. l 102(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 1 I " 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 .1 108
❑ 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

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 .I 104(d)(4) and current Division Policy
available at: http://www.newater,org/Rules Policies_ and_Regulation_s/. 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(d)(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 fixed supply systems)
❑ Submit a completed and accurate water balance in accordance with 15A NCAC 02T .1 104(d)(5} and current Division Policy
available at: http://www.ncwater.orgZRules Policies and Re gulationsl.
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 .0107(f}, 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
Division of Water Resources 15A NCAC 02T .1100 —
State of North Carolina
Department of Environmental Quality
Division of Water Resources
RESIDUALS LAND APPLICATION PROGRAM
FORM: RLAP 06-16
1. APPLICANT INFORMATION:
1. Applicant's name: City of Belmont
Applicant type: ❑ Individual ❑ Corporation ❑ General Partnership ❑ Privately -Owned Public Utility
❑ Federal ❑ State ® Municipal
❑ County
Signature authority's name per 15A NCAC 02T .0106: Adrian Miller
Title: City Manapzer
Applicant's mailing address: PO Box 431
City: Belmont State: NC Zip: 28012
Telephone number: [phone] Email Address: amiller(a),cityofbelmont.org
2. Consultant's name: Zach Key License Number (for P.E.):
Affiliation: ❑ On Staff ® Retained (Firm: US Biosolids, Inc.)
Consultant's mailing address: 958 Hoots Road
City: Roaring State: NC Zip: 28669-9148
Telephone number: [phone] Email Address: zachkey@usbiosolids.c_om
3. Agronomist's name: License Number:
Affiliation: [] NIA ❑ On Staff ❑ Retained (Firm: )
Agronomist's mailing address:
City: State: Zip: -
Telephone number: (_) = Email Address:
4. Soil Scientist's name: License Number:
Affiliation: ❑ NIA ❑ On Staff ❑ Retained (Firm: )
Soil Scientist's mailing address:
City: State: Zip: -
Telephone number: (_) = Email Address:
5. Fee submitted: $0.00 (See Instruction B)
11. PERMIT INFORMATION:
i. Application is for (check all that apply): El new, ❑ modified, ® renewed permit
2. If this application is being submitted to renew or modify an existing permit, provide the following:
Permit number: WQ000328I
Date of most -recently issued permit: 5-31-2016
Date of most -recently certified Attachment A (if different than the permit): 5-31-2016
Date of most -recently certified Attachment B. (if different than the permit): 5-31-2016
FORM: RLAP 06-16 Page] of5

III. RESIDUALS LAND APPLICATION PROGRAM INFORMATION:
1. Residuals Processing Facility's physical address: 298 Parkdale Drive
City: Belmont State: NC ,Zip: 28102
Coordinates: Latitude: 35' 13' 50" Longitude: 8 l ° 01' 50"
Datum: NAD83 Level of accuracy: 1"
Method of measurement: MAP
2. County where residuals land application program is headquartered: Gaston
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
Dennis Key
US Biosolids, Inc.
15704
Back -Up ORC
David Key
US Biosolids, Inc.
23629
Additional Back -Up
ORCs
(if applicable)
Zach Key
US Biosolids, Inc.
27660
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 Nitrogen Summary: Determine the maximum plant available nitrogen (PAN) generated by all residuals
source -generating facilities as currently certified and proposed for certification with this application and list the results in the
following table:
Maximum amount of residuals to be certified: 300 dry tons per year.
PAN
Pounds of PAN per Dry Ton
(Weighted Average)
Pounds of PAN per Year
Surface
Incorporation
or Injection
Surface
Incorporation
or Injection
First -Year
28.442
31.772
8532.6
9531.6
Five -Year Maximum Adjusted
30.43
33.99
9129
10197.6
b. Laud APnlicativir Site Use Sumniar : Summarize information regarding the land application sites as currently certified and
proposed for certification with this application:
Category
Use
Acres
Comments
Crops
Forest or Plantation
0
Row Crops
0
Hay
42A
Pasture
39.9
Total:
82.3
Methods
Surface
82.3
Incorporation or Injection
0
Total:
82.3
FORM: RLAP 06-16 Page 2 of 5

c. Residuals Land Application Suntmary: 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
(16s PAN/ac yr)
Concentrations
Surface
Incorporation or
Surface
Incorporation or
Injection
Injection
50
170.65
190.63
182.58
203.9
100
85.32
95.31
91.29
101.95
150
56.88
63.54
60.86
67.98
200
42.66
47.65
45.64
50.97
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): E 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.
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 system only.
VI. DESIGN INFORMATION FOR FIXED IRRIGATION SYSTEM
I. 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 02T .0505 _ 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:
S. Loading rates recommended by the Soil Scientist Evaluation:
Soil Series
Fields within Soil Area
Recommended
Loading Rate
in/hr
Recommended
Loading Rate
inl 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):
Spray Irrigation Design Element
Plan Sheet
Number
pecification
FlpsageNumber
Wetted diameter of nozzles
ft
Wetted area of nozzles
ft'-
Nozzle capacity
gpm
Nozzle manufacturer / model
/
Elevation of highest nozzle
ft
FORM: RLAP 06-16 Page 4 of 5

Applicant's Certification (signing authority must he in compliance with 15A NCAC 02T .0106):
The applicant or any affiliate has not been convicted of an environmental crime, has not abandoned a wastewater facility without proper
closure, does not have an outstanding civil penalty where all appeals have been exhausted or abandoned, are compliant with any active
compliance schedule, and do not have any overdue annual fees under Mule 15A NCAC 02T .0105.
® Yes ❑ No, Explain;
1, Adrian Miller rn� �_. City Manager
(Signature Authority's Name PLEASE PRINT) (Title)
attest that this application for City of Belmont. WW i'P
(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 § 143-215.6B, 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 aline not to
exceed S 10,000 as well as civil penalties up to $25,000 per violation.
Signature: '44 Date:
1211./20
FORM: RLAP 06-16 Page 5 of 5

Operation and Maintenance Plan
City of Belmont
Permit No. WQ0003281
In accordance to the requirements set forth by the North Carolina
Department of Environmental Quality using
NCGS 143-215.1 and 143-215.3{a} based on 15A NCAC 02T .1 10, The City
of Belmont is implementing this Operation and Maintenance Plan.
The project manager of the land application event will make sure a daily
check off is performed at the start of each work day. This inspection is to
prevent any spills, leaks, or run-offs.
The daily check -off will consist of inspection the following items:
1. Access to the facility will be controlled with a locked gate and
signs to prevent any unauthorized entry into the complex.
2. All pumps and hose will be checked at the start of each day for
leaks or loose fittings.
3. All tanker valves are closed prior to loading and lids are closed
prior to transport.
4. All dump Trailers or dump trucks gates are tightly fastened and
do not leak prior to transport.
5. All on road equipment is check as per DOT regulations for any
safety or mechanical hazards or issues.
6. All equipment is secured at the end of each working day to
prevent ❑ny tampering or unauthorized use.
The ORC or back up ORC will inspect the field after each land application
event to make sure all regulations as required by the permit are followed.
Also the project manager at the end of each working day during a land
application event will make sure that all gates if present are closed.
All samples shall be taken as early as possible before the first application
event of the calendar year to make sure the facility is compliance.
The samples will be taken in a matter that is representative of the residuals
and all grab samples will be mixed prior to be placed in to the containers

that will go to the laboratory. These samples must be collected and
transported as outlined in the Sampling Plan attached to this O&M Plan.
All records of these laboratory results as well as the annual report and
loading rates will be kept on file for a minimum of five (5) years.
Also, in the unlikely event of a spill or unintended release of residuals,
actions should be immediately taken as outlined in a copy of the
spill control plan attached.

City of Belmont, WWTP
Permit No. WQ0003281
SAMPLING PLAN
Annually, if a land application event occurs, grab samples are collected from the sludge holding
tank and digesters. These samples will be combined to form individual grab samples to be sent to a
laboratory for analysis. If a land application event is to occur in the early part of a calendar year (i.e.
January or early February) these samples may have to be taken in December so results can be obtained
before the land application event, as some results take 30+ days to receive.
These individual grab samples are collected and tested for fecal coliform analysis, volatile solids
reduction, nutrient analysis, and a TCLP test. These tests will be taken by U.S Biosolids, Inc. All samples
with the exception of the composite residual sample will be taken to Statesville Analytical. The
composite residual sample will be sent to Waypoint Analytical. All samples taken will be taken in the
same condition as the residuals are to be land applied.
The volatile solids reduction requirement will first be attempted by using option 1 1503.33(b)
(1)]; Reduction of volatile solids by at least 38%, The "IN" sample will be taken from the digester and the
"OUT" sample from the sludge holding tank. If this requirement can't be met, a gallon of residuals will
be sampled from the sludge holding tank and analyzed for option 3 503.33(b) (3); known as a 30 day
bench scale. This test requires less than 15% additional volatile solids reduction during bench -scale
aerobic batch digestion for 30 days.
Fecal Coliform are gather in seven (7) individual samples from the sludge holding tank and
tested to meet the requirements of (503.32(b)(2)]. This requirement is for the geometric mean fecal
coliform density of the samples be less than two million (2,000,000) MPN per gram. These samples will
be placed in 250ml containers and placed on ice, in a cooler for transport to the laboratory before 1600
hours (4pm) the same day the samples are obtained.
Annually, if land application occurs, a composite residual sample will be collected from the
sludge holding tank and analyzed, prior to a land application event for: Cadmium, Copper, Lead,
Mercury, Molybdenum, Nickel, Selenium, Zinc, Aluminum, Ammonia Nitrogen, Calcium, Nitrate
Nitrogen, Magnesium, % total Solids, pH, Phosphorus, Potassium, TKN, Sodium. From this information,
the Plant Available Nitrogen (PAN) and a Sodium Absorption Ratio (SAR) will be calculated. This sample
will collected in a non -breakable container, at least one quart in size.
A full TCLP test, including corrosivity, ignitability, and reactivity will be taken in two (2) gallon
containers from the sludge holding tank. This test will be run annually, unless prior approval is granted
from the division to reduce this requirement to once per permit cycle.

SPILL CONTROL PLAN- U.S. Biosolids, Inc.
City of Belmont, NC-_WQ.0003281
In the event of a spill, the following should be taken IMMEDIITALY.
1. Make sure all personal and bystanders are safe- if not contact emergency
services
2. Halt the source of the spill- overturned truck, leaking valve, ruptured tank.
3. Contain the spill. Use straw bales or earthen barrier to form a dike to contain the
spill.
4. Cleanup. Employ vacuum trucks, dump trucks, and loaders to remove as much
of the spilled material as possible. Use straw to soak -up the remaining material.
Dispose of the same in a landfill.
5. Flush the roadways with water if needed. If the spill occurred on a tillable area, till
the some into the soil and spread lime if necessary. If a spill occurs on private
property, final clean-up should be to the satisfaction of the owner.
6. Notification. (This should be done as soon as safely possible.)
A. U.S. Biosolids, Inc. Main Office [phone]
B. City of Belmont, WWTP- Tanya Carter [phone]

C. NCDEQ-Mooresville Regional Office [phone]
D. County Emergency Services (Sheriff, fire Dept.) 911
7. Reporting:
The Permittee shall report by telephone to the Mooresville Regional Office,
telephone number [phone], as soon as possible, but in no case more than
24 hours or on the next working day following the occurrence or first knowledge
of the occurrence of any of the following:
A. Surface disposal of residuals abnormal in quantity or characteristic.
B. Any failure of the surface disposal program resulting in a release of
material to surface waters.
C. Any time self -monitoring indicates the facility has gone out of compliance
with its permit limitations.
D. Any process unit failure, due to known or unknown reasons, rendering the
facility incapable of adequate residual treatment
E. Any spill or discharge from a vehicle or piping system during residuals
transportation.
Any emergency requiring immediate reporting (e.g., discharges to surface
waters, imminent failure of a storage structure, etc.) outside of normal business
hours shall be reported to the Division's Emergency Response personnel at
telephone number [phone], [phone], or [phone]. Persons
reporting such occurrences by telephone shall also file a written report in letter
form within five days following first knowledge of the occurrence. This report shall
outline the actions taken or proposed to be taken to ensure that the problem
does not recur.
8. Spill Prevention. The easiest way to clean a spill is to prevent one.
A. Ensure loading personal watch the vehicle being loaded.
B. Ensure all valves and lids are closed
C. Inspect all seals and replace if necessary.

State of North Carolina
DWR
Department of Environmental Quality
Division of Water Resources
Dlvlslon 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 I I-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 Applicagon Permrts".
Residuals
❑ 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. 8.
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 l

RESIDUALS SOURCE FACILITY SUMMARY
Applicant's name: City of Belmont
Status I Maximum Dry Tons Per Year
Code" Facility Permit Holder Facility Name County Permit Number
Current ° Proposed
R City of Belmont City of Belmont W WTP Gaston WQ0003281 300 300
0
Status Code for source facility are: + N (New) ♦ R (Renewed) ♦ M (Modified) ♦ D (Deleted)
The amount of residuals currently permitted for distribution. land application, or disposal (i.e. not applicable to new facility).
SUMMARY FOR FORM: RSC 06-16 Page I

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
RESIDUALS SOURCE CERTIFICATION
FORM: RSC 06-16
I. RESIDUALS SOURCE -GENERATING FACILITY INFORMATION (See Instruction B.):
1. Facility Name: City of Belmont Waste Water Treatment Plant
2. Facility permit holder is: Federal, [] State, 0 Local Government, or d Private.
Facility permit issued by: ❑ Div. of Water Resources, El Div. of Environmental Health,
or ] Other (explain ).
3. Facility contact person and title: Tanya S. Carter, W WTP Superintendent-ORC
Complete mailing address: PO Box 431
City: Belmont State: NC Zip: 28012
Telephone number: [phone] E-mail address. tsetzeri cit ofbelmont.or
4. Facility physical address: 298 Parkdale Drive
City: Belmont State: NC Zip: 28012
Coordinates: Latitude: 35' 13' 50.54" Longitude: 81 ° 01 ` 03.61 "
Datum: WGS84 Level of accuracy: ±.OI
Method of measurement: MAP
5. Purpose of the facility:
0 treatment of municipal wastewater, 0 treatment of 100% domestic wastewater,
0 treatment of potable water, Q 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: 5 MGD and facility average daily flow: 3_2 MGD
8. Average amount of residuals being generated at this facility 99.26 dry tons per year.
9. Specify the following regarding treatment and storage volumes available at the facility:
Type and volume of residuals treatment: 1.7 Million Gallon Sludge Holdin 'rank
Type and volume of residuals storage (i.e., outside of residuals treatment units):
II. RESIDUALS QUALITY INFORMATION (See Instruction C.):
I . Specify if residuals are regulated under:
M 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. l 102(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-I6 Page l 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: 0 yes 0 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 E 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: PACE Analytical and Date of analysis: 8/18/2020
Passed corrosivity test: M yes [] no. pH: s.u. (2 < pH < 12.5)
Passed ignitability test: JZ yes Q no. Flashpoint: 200 IF (> 140°F)
Passed reactivity test: Oyes ,Ono. HCN: ND mglkg (<250) & H2S: ND mg/kg (<500)
TCLP Parameter
Limit
(nrgll)
Result
(M910
TCLP Parameter
Limit
(M9/0
Result
(m9/0
Arsenic
5.0
ND
Hexachlorobenzene
0.13
ND
Barium
100.0
ND
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
a 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
O.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 .1 105.
a. For Distribution/Lard 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: 8/18/2020
Parameter
Ceiling
Concentration Limits
(ClassA & ClassB)
(mg/kg)
Monthly Average
Concentration Limits
(Class A Only)
(mg/kg)
Result
(mg/kg)
Arsenic
75
41
12.5
Cadmium
85
39
2.5
Copper
4,300
1,500
343
Lead
840
300
31.3
Mercury
57
17
0.973
Molybdenum
75
n/a
6.25
Nickel
420
420
23.2
Selenium
100
100
12.5
Zinc
7,500
2,800
1610
b. For Surface Disposal Unit (landDll): 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/kgj
Nickel
(mg/kg)
> 0 but < 25
30
200
210
[❑ > 25 but < 50
34
220
240
> 50 but < 75
39
260
270
E > 75 but < 100
46
300
320
> 100 but < 125
53
360
390
El > 125
62
450
420
Result (mg/kg)
FORM: RSC 06-16 Page 3 of

5. Nutrient/Micronutrient Determination: Complete the following:
a. Total solids: 3.95 %.
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: 08/18/2020
Parameter
Result
(mg/kg)
Aluminum
47800
Ammonia -Nitrogen
3330
Calcium
13100
Magnesium
3080
Nitrate -Nitrite Nitrogen
35
pH (Standard Unit)
7,3
Phosphorus
22200
Potassium
2650
Sodium
6100
Total Kjeldahl Nitrogen
44000
c. Using the results listed in Item 11. 5b. above, calculate the sodium adsorption ration (SAR): 0,417
[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: 30 %. This
rate is a (check one): Z default value, or Q 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 (V) Year PAN
Five -Year
Maximum Adjusted PAN
img�kg�
(mg/kg)
Surface
14221
15216.5
Injection/Incorporation
15886
16998
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:
FORM: RSC 06-16 Page 4 of 5

7. Pathogen Reduction: Per 15A NCAC 02T.1 106, specify how residuals will meet the pathogen reduction requirements:
a. For Distribution/Land Application of Class A or Equivalent:
El A fecal coli form density that is demonstrated to be less than 1,000 MPN per gram of total dry solids,
or
0 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 I [15A NCAC 02T.1 106(b)(3)(A)] - Time/Temperature Compliance.
[] Alternative 2 [15A NCAC 02T. I I06(b)(3)(B)] - Alkaline Treatment.
0 Alternative 3 [15A NCAC 02T.1 106(b)(3)(C)] - Prior Testing for Enteric Virus/Viable Helminth Ova.
[] Alternative 4 [15A NCAC 02T.1 106(b)(3)(13)] - 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: EJ composting, E] heat drying, n heat treatment,
Q thermophilic aerobic digestion, beta ray irradiation,
Q gamma ray irradiation, or H pasteurization.
b. For Land Application of Class B:
Alternative 1 [15A NCAC 02T.I 106(c)(1)] - Fecal Coliform Density Demonstration.
0 Alternative 2 [15A NCAC 02T.1 106(c)(2)] - Process to Significantly Reduce Pathogens (PSRP).
Specify one: 0 aerobic digestion, 0 air drying, El anaerobic digestion,
composting, or .0 lime stabilization.
c. For Surface Disposal:
[] Select One of the Class A or Equivalent Pathogen Reduction Alternatives in Item H. 7a. above.
0 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.1 106(a)(2)].
❑ Not Applicable - Non -Biological Residuals with NO Domestic Wastewater Contribution.
8. Vector Attraction Reduction (VAR): Per 15A NCAC 02T.1 107, specify how residuals will meet the VAR requirements:
0 Alternative 1 [15A NCAC 02T.1 107(a)(1)] - 38% Volatile Solids Reduction (Aerobic/Anaerobic Digestion).
El Alternative 2 [15A NCAC 02T.1 107(a)(2)] - 40-Day Bench Scale Test (Anaerobic Digestion).
ED Alternative 3 [15A NCAC 02T.1 107(a)(3)] - 30-Day Bench Scale Test (Aerobic Digestion).
Alternative 4 [15A NCAC 02T. 1107(a)(4)] - Specific Oxygen Uptake Rate Test (Aerobic Digestion).
Ll Alternative 5 [15A NCAC 02T.1 107(a)(5)] - 14-Day Aerobic Processes.
El Alternative 6 [15A NCAC 02TA 107(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.1 107(a)(9)] -Injection.
Alternative 10 [15A NCAC 02T.1107(a)(10)] -Incorporation.
[] Alternative for Surface Disposal Units Only - Soil/Other Material Cover [15A NCAC 02TA 107(b)(2)].
0 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

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Quantitative Justification for Residuals Production Rate:
In the 7 last years, the City of Belmont Wastewater Treatment Plant has produced the following number
of residuals in Dry Tons per year.
YEAR
DRY TONS
2013
85.7
2014
99.26
2015
164.98
2016
213.85
2017
116.5
2018
54.04 _
2019
84.76
This is an average of 117.01 Dry Tons per year, which is less than the 300 dry tons currently allowed by
permit WQ0003281. This will allow any growth that the Waste Water Treatment Plant may occur during
the next permit cycle.

City of Belmont, WWTP
Permit No. WQ0003281
SAMPLING PLAN
Annually, if a land application event occurs, grab samples are collected from the sludge holding
tank and digesters. These samples will be combined to form individual grab samples to be sent to a
laboratory for analysis. if a land application event is to occur in the early part of a calendar year (i.e.
January or early February) these samples may have to be taken in December so results can be obtained
before the land application event, as some results take 30+ days to receive.
These individual grab samples are collected and tested for fecal coliform analysis, volatile solids
reduction, nutrient analysis, and a TCLP test. These tests will be taken by U.S Biosolids, Inc. All samples
with the exception of the composite residual sample will be taken to Statesville Analytical. The
composite residual sample will be sent to Waypoint Analytical. All samples taken will be taken in the
same condition as the residuals are to be land applied.
The volatile solids reduction requirement will first be attempted by using option 1 [503.33(b)
(1)]; Reduction of volatile solids by at least 38%. The "IN" sample will be taken from the digester and the
"OUT" sample from the sludge holding tank. If this requirement can't be met, a gallon of residuals will
be sampled from the sludge holding tank and analyzed for option 3 503.33(b) (3); known as a 30 day
bench scale. This test requires less than 15% additional volatile solids reduction during bench -scale
aerobic batch digestion for 30 days.
Fecal Coliform are gather in seven (7) individual samples from the sludge holding tank and
tested to meet the requirements of [503.32(b)(2)]. This requirement is for the geometric mean fecal
coliform density of the samples be less than two million (2,000,000) MPN per gram. These samples will
be placed in 250ml containers and placed on ice, in a cooler for transport to the laboratory before 1600
hours (4pm) the same day the samples are obtained.
Annually, if land application occurs, a composite residual sample will be collected from the
sludge holding tank and analyzed, prior to a land application event for: Cadmium, Copper, Lead,
Mercury, Molybdenum, Nickel, Selenium, Zinc, Aluminum, Ammonia Nitrogen, Calcium, Nitrate
Nitrogen, Magnesium, % total Solids, pH, Phosphorus, Potassium, TKN, Sodium. From this information,
the Plant Available Nitrogen (PAN) and a Sodium Absorption Ratio (SAR) will be calculated. This sample
will collected in a non -breakable container, at least one quart in size.
A full TCLP test, including corrosivity, ignitability, and reactivity will be taken in two (2) gallon
containers from the sludge holding tank. This test will be run annually, unless prior approval is granted
from the division to reduce this requirement to once per permit cycle.

LABORATORY
DATA

Waypoint(2)
ANALYTICAL
46381
Southern Soil Builders
Dennis Key
958 Hoots Road
Roaring River , NC 28669
Report Number :20-237.0007
Lab No : 73436
Sample ID : Belmont
Project Belmont
Information :
1521 Whitepkie Road, Richmond, VA 23237
Main 804-743.9401 ° Fax [phone]
www.waypointa nalyticat. corn
REPORT OFANAL PSIS
Report Date : 09/01/2020
Received : 08/24/202f)
` �7 Q, W
R3uric Mc Groary Ph.D., CPA
Agronomist
Matrix: Solids
Sampled: 8/18/2020 13:15
Test Results Units MQL DF Date / Time 13y Analytical
Analyzed Method
Moisture 96.0 % 0.010 1 08/25/2014:11 FMM SM-2540G
Test Results Units MQL DF Date 1 Time By Analytical
Analyzed Method
Ammonia Nitrogen
3330
mg/Kg - dry
625
1
08/31/20 I5:45
JPJ
SM-4500-NH3(:
Nitrates Nitrite-N
355
mg/Kq - dry
123
1
08/26/20 14:45
ZBD
450ONO3F-2011
Organic. N
40800
mg/Kg - dry
6250
1
08/31/20 10:00
CALCULATION
pH
7.3
s,u.
1
08/26/2013:05
ADM
9045D
Total Solids
3.95
%
0.010
1
08/25/20 14:11
FMM
SM-2540G
Total Kjeldahl Nitrogen
44000
mg/Kg - dry
6250
1
08/31/20 10:00
)PJ
iM-4500-NH3C-TKP
Phosphorus
22200
mg/Kg - dry
125
1
08/28/20 04:24
]ADS
6010D
Aluminum
47800
mg/Kg - dry
125
1
08/28/20 04:24
T7S
6010D
Arsenic
<12.5
mg/Kg - dry
12.5
1
08/28/20 04:24
DADS
6010D
Calcium
13100
mg/Kg - dry
1250
l
08/28/20 04:24
JARS
6010D
Cadmium
<2.50
mg/Kg - dry
2.50
a
08/28/20 04:24
]ADS
60100
Chromium
91.8
mg/Kg - dry
6.25
.1
08/28/21) 04:24
]ADS
6010D
Copper
343
mg/Kg - dry
12.5
€
08/28/20 04:24
.]ADS
6010D
Iron
26800
mg/Kq - dry
250
1
08/28/20 04:24
DADS
601 OD
Lead
31.3
mg/Kg - dry
7.50
1
08/28/20 04:24
DADS
6010D
Magnesium
3080
mg/Kg - dry
125
1
08/28/20 04:24
]ADS
6010D
Manganese
1130
my/Kg - dry
12.5
1
08/28/20 04:24
TJS
6010D
Qualifiers/ DF
Dilution Factor
L
Limit Exceeded
Definitions MQL
Method Quantitation Limit
Page 3 of 6

s
Way nt(2)
7621 Wh 804-7
Road, Richmond, VA 23237
PANALYTICAL
Main SU4-%43.94U1 °Fax 80�€•273-6446
www-waypointanalytical.com
46381
Southern Soil Builders
Project
Belmont
Dennis Key
Report Date : 09/01/2020
958 Hoots Road
Information ;
Received : 08/24/2020
Roaring River , NC 28669
m
Pauric Mc Groary Ph.D., CPA
Report Number : 20-237-0007
REPORT OFANALYSIS
Agronomist
Lab No : 73436
Matrix:
Solids
Sample 1D : Belmont
Sampled:
8/18/2020 13:15
Test
Results
Units
MOL
DF
Date / Time
By Analytical
Analyzed
Method
Mercury
0.973
mg/Kg - dry
0.363
1
08/27/20 12:10
DDB SW-7471B
Molybdenum
<6.25
mg/K9 - dry
6.25
1
08/28/20 04:24
]ADS 6010D
Nickel
23.2
mg/Kg - dry
6.25
1
08/28/20 04:24
)ADS 6010D
Potassium
2650
mg/Kg - dry
250
1
08/28/20 04:24
JADS 6010D
Selenium
<12.5
mg/Kg - dry
12.5
1
08/28/20 04:24
JADS 60i0D
Sodium
6100
mg/Kg - dry
625
1
08/28/20 01:24
]ADS 6010D
Zinc.
1610
mg/Kg - dry
31.3
1
08/28/20 04:24
]ADS 6010D
Sulfur
10100
mg/Kg - dry
250
1
08/28/20 04:24
]ADS 6010D
Qualifiers/ DF Dilution Factor
Definitions MQL Method Quantitation Limit
L Limit Exceeded
Page 4 of 6

PAN
Mineralization
Rate I TKN i
NH3
I NO3 1
0.3 I 44000 1
3330
355
PAN Surface
14221 mglkg
28.442 Ibsldry ton
0
Ibs total PAN
#DIVIO!
lbs PANlacre
PAN Injection
15885 mgikg
31.772 Ibs/dry ton
0
Ibs total AN
#DIV/O! jibs
PAN/acre
Dry Tons/1000 gal.
0.164715
1st year PAN
Ibs./acre
Surface Ibs.
su face
0
#DIV/0!
1st year PAN
lbs.lacre
Injected Ibs.
Injected
01
#DIV/0!
�as decimal JTotal dry Acres
NO2 I % Sr Hds t�ncluoar bnr+liewl nn I
0 - 0.0395 ,
MR(TKN-NH3)+ + .5(NH3 )+NO3+NO2 =mgikg
mg/kg x .002 =Ibsldry ton
MR(TKN-NH3) + l(NH3)+NO3+ NO2 =mgikg
mglkg x .002 =Ibsldry ton
1000 X 8.34 X %solids X sip. gravit "=dry tons/1000ga1."
2000

SAR
Sodium Absorption Ratio
Na : Sodium (MgIL) Equivalent weight: 23
Ca : Calcium (MgIL) Equivalent weight: 20
Mg : Magnesium (MgIL) Equivalent weight: 12
Milli Equivalent = MgIL I Equivalent weight
Na M It Ca M IL Mg MIL
240.95 1 517.45 1 121.66
Na.(M,E) Ca„�MEa. M,g._iME.)
10.47609 25,8725 10.13833
SAR= Na Milli Equivalent/[0.5 X (Ca Milli Equivalent + Mg Milli equivalent)]0 5 power
SAR = 2.468866 (From MgIL entered above)
SAR= 0.417061 ](From ME entered below)
Na (ME)
Ca (ME)
Mg (ME)
0.29
1 0.328
1 0.639
The amour
amount of E
Permitting

Analytical Results
U.S. Biosolids Inc
968 Hoots Road
Roaring River, NC 28669
Receive Date: 08/18/2020
Reported: 09/22/2020
For: Belmont
Comments:
AIr 'A L'. 3 I L
Sample Number Parameter Sample ID Result Unit Method Analyzed Analyst
200818-27-01 30 Day Benchscale BELMONT <1 % EPA625,R-9210 081111/2020 WC
Respectfully submitted,
Dena Myers
NC Cert #440,
NCDW Cert #37755,
EPA #NC00909
PO Box 228 a Statesville, NC 28687 a 704/872/4697
Page 1 of 2

Analytical Results
U.S. Biosolids Inc
958 Hoots Road
Roaring River, NC 28669
Receive Date: 08/18/2020
Reported: 08/20/2020
For:
Comments: GEOMETRIC MEAN: 558 MPN/g
Sample Number
Parameter
Sample ID
Result
Unit
Method
Analyzed
Analyst
200818-25-01
Fecal Coliforms
131
915
MPN/g
SM92210E-2006
08/19/2020
MD
200818-25-01
Percent Solids
61
4.37
%
SM25405-2011
08/19/2020
MD
200818-25-02
Fecal Coliforms
B2
444
MPNIg
SM92210E-2006
08/19/2020
MD
200818-25-02
Percent Solids
132
4.5
%
SM25406-2011
08119/2020
MD
200818-25-03
Fecal Coliforms
B3
<452
MPNIg
SM92210E-2006
08/19/2020
MD
200818-25-03
Percent Solids
63
4.42
%
SM254OB-2011
08/19/2020
MD
200818-25-04
Fecal Coliforms
64
463
MPNIg
SM92210E-2006
08119/2020
MD
200818-25-04
Percent Solids
64
4.32
%
SM254OB-2011
08/19/2020
MD
200818-25-05
Fecal Coliforms
65
<472
MPNIg
SM92210E-2006
08119/2020
MD
200818-25-05
Percent Solids
85
4,24
aka
SM25406-2011
08/19/2020
MD
200818-25-06
Fecal Coliforms
B6
942
MPN/g
SM92210E-2006
08/19/2020
MD
200818-25-06
Percent Solids
66
4.25
%
SM25406-2011
08/19/2020
MD
200818-25-07
Fecal Coliforms
B7
446
MPNIg
SM92210E•2006
08/19/2020
MO
200818-25-07
Percent Solids
B7
4.48
%
SM2540B.2011
08/19/2020
MD
Respectfully submitted,
Dena Myers
NC Cert #440,
NCDW Cert #37755,
EPA #NC00909
PO Box 228 • Statesville, NC 28687 • 704/872/4697
Page 1 of 4

Analytical Results
U.S. Biosolids Inc
958 Hoots Road
Roaring River, NC 28669
Receive Date: 08/18/2020
Reported: 09/08/2020
For: BELMONT
Comments:
Sample Number
Parameter
Sample ID Result
Unit Method
Analyzed
Analyst
200818-26-01
Corrosivity
See Attached
sw-eas
08/20/2020
PACE
200818-26-01
Ignitability
See Attached
1010M
08/20/2020
PACE
200818-26-01
Reactivity
See Attaches!
SW-846
08/20/2020
PACE
200818-26-01
TCLP
See Attached
8sNot8d
08/20/2020
PACE
Respectfully submitted,
Dena Myers
NC Cert #440,
NCDW Cert #37755,
EPA #NC00909
PO Box 228 a Statesville, NC 28687 a 704/872/4697
Page 1 of 30

aceAnalj4cal
anrw.'aala6a.een
r
Pace Analytical Services, LLC
9800 KinceyAve. Suite 100
Huntersvitle, NG 28078
(704)1175.9092
Project: Belmont
Pace Project No.: 92491728
ANALYTICAL RESULTS
Sample: 200818.26.01
Lab 10: 92491728001 Collected: 08/18/20 13:05 Received; 08/2012011A7 Matrix: Solid
Results repor4ed on a 'dry weight' basis and are adjusted for percent moisture, sample size and arty dilutions.
Parameters
Results Units Report Limit OF Prepared Analyzed CAS No. Qual
Chlorinated Herb. (GC) 8161A
Analytical Method: EPA8151A Preparation Method: 8151A
Leachate MethodlDete: 1311: 08/25/20 09:28 Initial pH: 6.74: Final pK 4.92
Pace National - Mt. Juliet
2,4,5-TP(Silvex)
NO mglL 0,00200 1 0812712006:55 08127t2013:12 93.72-1
2.4.0
ND rnWL 0,00200 1 08/27/20 06:55 08/27/20 13:12 94.75-7
Surrogates
2,4-DCAA(S)
49.2 % 14.0.158 1 08127t2006:55 08127/2013:12 19719-28-9
8081 TCLP Pesticides RVE
Analytical Method: EPA6081B Preparation Method: EPA 3510C
Leachate MethodlDate: EPA 1311; 08126t20 12:00 Initial pH: 4.99, Final plf 5
Pace Analytical Services - Charlotte
gamma-BHC (Undane)
No uglL 0.50 1 09/02/20 13,00 09103120 12:23 58-89-9
Chlordane (Technical)
NO uglL 3.0 1 09/02/20 13:00 09/03/20 12:23 57-74-9
Endrin
ND ug1L 0,50 i 09/0212013:00 09103/2012:23 72-20-8
Heptachlor
NO uglL 0.50 1 09102t2013:00 0910312012:23 76.44-8
Heptachlor epoxide
NO uglL 0,60 1 09/02/20 13:00 09103120 12:23 1024-57.3
Methoxychlor
NO ug1L 1000 1 G9102/2013:00 0910312012:23 72.43-5
Toxaphene
Surrogates
NO ug1L 3.0 1 0910272013:00 09103/2012:23 8001-35-2
Decachlorobiphenyl (S)
124 % 10-154 1 09/02120 13:00 09/03/20 12:23 2051-24-3
TeVachioro-m-xylene (8)
44 % 10.184 1 09/02/20 13:00 09/03/20 12:23 877-09-8
8082 TCLP PCBs RYE
Analytical Method; EPA 8082A Preparation Method: EPA 3510C
Leachate Method/Date: EPA 1311; 08/26120 12:00 Initial pH: 4.99; Final pH: 5
Pace Analytical Services - Charlotte
PCB-1016 (Aroclor 1015)
NO ug1L 1000 1 09/02120 08A4 09103t20 05:49 12674-11-2
PCB-1221 (Aroclor 1221)
NO ug1L 1000 1 09102t20 08:44 09/03/20 05:49 11104-28-2
PCB-1232 (Aroclor 1232)
NO uglL 1000 1 09/02/20 08:44 09103/20 05749 11141.16-5
PCB-1242 (Arodor 1242)
NO uglL 1000 1 09/02/20 08:44 09/03/2005:49 53469-21-9
PC9.1248 (Aroclor 1248)
ND ugtL 1000 1 09102/20 08:44 09/03/20 05:49 12672.29-6
PCB-1254 (Aroclor 1254)
NO uglL 1000 1 09102/20 08:44 09/03120 05:49 11097-69-1
PC6.1260 (Aroclor 1260)
Surrogates
NO ug1L 1000 1 09Y02120 06:44 09/03/20 05:49 11096-82.5
Decachlorobiphenyl (S)
114 % 10.181 1 09102J20 08:44 09103120 05:49 2051-24.3
6010 MET ICP, TCLP
Analytical Method; EPA 6010D Preparation Method; EPA 3010A
Leachate Method/Date: EPA 1311, 08/26/20 13:00 Initial pH: 5-9: Final pH: 2
Pace Analytical Services - Asheville
Arsenic
Barium
NO mg1L 0,050 1 08/28/20 02:21 08/29120 2211 7440.38-2
Cadmium
NO mglL 0.25 1 08128/20 02:21 08129120 22:11 7440.39-3
Chromium
NO mgfL 0.0050 1 08/28121)02:21 08/29/20 2211 7440-43-9
Lead
ND mgfL 0.050 1 08/28120 02-21 08129/20 22:11 7440-47.3
Selenium
ND mg1L 0.025 1 08/28/20 02:21 08/29/20 22:11 7439-92-1
Silver
NO mgfL 0.10 1 08I28/20 02:21 08129/20 22:11 7782-49-2
NO mg1L 0.025 1 08128/20 02:21 08129/20 22:11 7440.22-4
REPORT OF LABORATORY ANALYSIS
This report Shall not he reproduced, except in full,
Date: 09104/2020 05:01 PM
without the v tten consent of PaceAnalylical Services, I.I.C.
Page 5 of 27
PO Box 228 a Statesville, NC 28687 a 704/872/4697
Page 8 of 30

IceAnaI34ical'
ANALYTICAL RESULTS
Pace Analytical Services, LLG
9800 Kincey Ave. Suite too
Huntersville. HC 28078
[phone]
Project: Belmont
Pace Project No.: 92491728
Sample: 200818.25.01
Lab $D: 92491728001 Collected: 0811a/20 13:05 Received: 08/20/20 11:47 Matrix: Solid
Results reported on a 'dry weight'
basis and are adjusted for percent moisture, sample size and any dilutions.
Parameters
Results Units Report Limit DF
Prepared Analyzed CAS No. Qual
7470 Mercury, TCLP
Analytical Method: EPA7470A Preparation Method: EPA 7470A
Leachato MethodlDate: EPA 1311. OV2012013:00 rnitial
pH: 5.9; Final pH: 2
Pace Analytical Services -Asheville
Mercury
ND mglL O.00020 1
08128/2010:00 0812812012A6 7439.97-6
8270E TCLP RVE
Analytical Method: EPA 8270E Preparation Method: EPA 351 OC
Leachate Method/Date: EPA 1311; 08/25120 12:00 Initial
pH: 4.99; Final pH: 5
Pace Analytical Services - Charlotte
1,4-Dichiorobenzens
2,4-Dinitrotoluene
ND ug1L 50.0 1
09102/2011:02 0910312012:31 106-46-7
Hexachloro-1,3-butadione
ND ug1L 50.0 1
ND
0910212011:02 0910312012:31 121-14.2
Hexachforobenzeris
ug1L 50.0 1
NO
0910212011:02 0910312012:31 87.68-3
Hexachroreelharle
uglL 50.0 1
ND
0910212011-02 0910312012:31 118-74-1
2-Methylphenol(o-Cresol)
ug1L 50.0 1
NO
09/0212011:02 0910312012:31 67-72-1
3&4-Melhylphenol(m&p Cresol)
uglL 50.0 1
ND ug1L
09/0212011;02 09103/2012:31 95-48-7
Nitrobenzene
50.0 1
ND uglL
09102/20 11:02 09103/20 12:31 15831.10-4
Pentachlorophenol
50.0 1
ND
09/0212011:02 09103f2012:31 98-95.3
Pyridine
ug1L f00 1
ND
0910212011A2 09/03/2012:31 87.86-5
2,4,5-Trichlorophenol
ug1L 50-0 1
ND ug1L
09102/2011:02 0910312012:31 110-86-1
2,4,6-Tnchlorophenot
50.0 1
ND uglL
0910212011:02 0910312012:31 95-954
Surrogates
%0 1
09/02120 11 :02 09/0312012:31 88-06.2
Nltrobenzene-d5 (S)
2-Fluorobiphenyl (S)
81 % 13-130 1
09/02/20 11:02 09/03/20 12:31 4165.6D-0
Terphenyl-d14 (6)
56 % 13-130 1
112
09/02/20 11:02 09103120 12:31 321-60.8
Phenol-d6 (9)
% 25.130 1
88
09/02/20 11:02 09103/20 12:31 1718-51-0
2-Fluorophenol (S)
% 10-130 1
76 %
09/02120 11:02 09/03/20 12:31 13127.88-3
2,4,6-Tribromophenol (S)
10.130 1
78 %
09102/20 11:02 09/03/20 12:31 367.12.4
10.137 1
09/02/20 11:02 09/03120 12 31 118-79.6
8260D MSV TCLP
Analytical Method: EPA 8260D Leachate MethodlDate:
EPA 1311: 08128/20 10:57
Pace Analytical Services -Charlotte
Benzene
2-Butanone (MEK)
ND ug1L 100 20
ND
08/30/20 20:56 71-93-2
Carbon tetrachloride
u 1L
9 20
ND uglL
08130/20 20:56 78-23-5
Chlroa
100
100 20
ND uglL
08130/20 20:56 56-23.5
Chloroform
100 20
ND ug1L
0813DI20 20:56 108-90-7
1A-Dichlorobenzene
100 20
ND ug1L tOO
00/30120 20:56 67-66•:3
1,2-Dichloroethane
20
ND ug1L
08/30/20 20:56 106-46.7
1,1-Didlloreethene
100 20
ND ug/L
08130120 20:56 107-06-2
Tetrachloroethene
100 20
NO u811
08/30120 20:56
Trichloroethane
100 20
ND ug1L
0830120 20:55 27-16.4
127-1S1
Vinyl chforide
100 20
ND u R
08130/20 20:56 79-01-6
Surrogates
0 100 20
08/30120 20:56 75-01.4
1,2-Dichloroethane-d4 (S)
706 % 70-130 20
Toluene-d8 (S)
107 %
D8130120 20:56 17060-07-0
4•Bromofluorobenzene (S)
87-135 20
103 %
08/30/20 20:56
70-130 20
08/30120 20:56 460.00-4
460.00-4
REPORT OF LABORATORY ANALYSIS
Date: 0910412020 05:01 PM
This repen Shall not be reproduced, except in full.
without the mitten Consent of Pace Anayt ,al Services, LLC,
Page 6 of 27
PO Box 228 • Statesville, NC 28687 1, 704/872/4697
Page 9 of 30

1C6Analytical
/WWkCF"&bL=5
i
ANALYTICAL RESULTS
Proje& $almond
Pace Project No.: 92491728
Pace Analylical Services, LLC
9800 KinceyAve. Suite 100
Huntersville, NC 2807E
p04$75.9092
sample: 2e0818.26.01
Lab ID; 92491728001 Collected: 08/18120 13:05 Received: 08/20/20 11:47 Matrix: Solid
Results reported on a "dry welght' basis and are adjusted for percent moisture, sample size and any dilutions.
Parameters
Results Units Report Limit OF Prepared Analyzed CAS No. Qual
Percent Moisture
Analytical Method: ASTM 02974-87
Pace Analytical Services - Charlotte
Percent Moisture
9616 % DA0 1 08120120 18:34
1010 Flashpoint Closed Cup
Analytical Method: EPA 1010A
Pace Analytical Services - Asheville
Flashpoint
>200 dog F 70.0 1 09102120 13:26
9045 pH Soil
Analytical Method: EPA 9045D
Pace Analytical Services - Asheville
pH at 25 Degrees C
6.7 Sid. Units 0.10 1 0812412014:27 H3
9095 Paint Filter Liquid Test
Analytical Method: EPA 9095B
Pace Analytical Services - Asheville
Free Liquids
Fall 1.0 1 08/25120 10:19
733C 3 Reactive Cyanide
Analytical Method: EPA 9014 Preparation Method: SW-846 7.3.3 2
Pace Analytical Services - Greensburg
Cyanide, Reactive
NO mglkg 29.2 1 08/24/20 17:48 08/25120 12:03
7348 Reactive Sulfide
Analytcal Method: SM 4500S2F-2011 Preparation Method: SW-846 7.3.4.2
Pace Analytical Services - Greensburg
Sulfide, Reactive
NO mglkg 292 1 08/24/20 17:48 08124/20 18:00
Sample: 200818.26.01
Lob 10. 92491728D02 Collected: 08/18120 13:05 Received: 09/20120 11:4 -Matrix: Water
Parameters
Results Units Report Limit DF Prepared Analyzed
CAS No. Qual
8082 GCS PCB RVE
Analytical Method: EPA 8082A Preparation Method: EPA 3510C
Pace Analytical Services - Charlotte
PCB-1016 (Aroclor 1016)
PCB-1221 (Arodor 1221)
NO uglL 5.0 1 09/04120 08:37 09104/20 14:51
12674-11-2
PCB-1232 (Aroclor 1232)
ND uglL 5.0 1 0910412008:37 09/(34120 14:51
ND uglL
11104-28.2
PCB-1242 (Arodor 1242)
5.0 1 09)04120 08:37 09/04/20 14:51
NO ug1L 5.0
11141-16.5
PCB-1248 (Arodor 1248)
1 09104/20 08:37 09104120 14:51
NO ug1L
53469-21-9
PCB-1254 (Arodor 1254)
5.0 1 09104/20 08:37 09104/20 14:51
ND ug1L
12672-29-6
PCS-1260 (Arodor 1260)
5.0 1 09104120 08:37 09/04120 14:51
ND uglL
11097-69-1
Surrogates
5.0 1 09/04/20 0837 09/04/20 14:51
11098-82-5
Decachlorobiphanyl (S)
125 % 10-181 1 09/04/20 08:37 09/04120 14:51
2051-24-3
REPORT OF LABORATORY ANALYSIS
Date: 09104/2020 05:01 PM
This report shall not be reproduced, except In Ul,
without the written consent or Pace Analytical Services, LLC.
Page % of 27
PO Box 228 • Statesville, NC 28687 a 704/872/4697
Page 10 of 30

State of North Carolina
15WRDepartment 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 on final 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 receiving sites for land application of Class B residuals (may include
water treatment plant or other type residuals) in accordance with 15A NCAC 02T .1 100. Do not submit this certification for review
without a corresponding application form (FORM: RLAP 06-16 or FORM: SDR 06-16).
Unless otherwise noted, the Applicant shall submit one original and two copies of the application and supporting documentation listed
below.
A. Land Application Site Certification (FORM: LASC 06-16):
❑ Submit the completed and appropriately executed Land Application Site Certification (FORM: LASC 06-16) form. Please
do not make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attachments
to the application may be made, as long as the attachments are numbered to correspond to the section and item to which they
refer.
❑ For new or renewed permits, submit the requested information for all land application sites.
❑ For modified permits, submit the requested information for only those sites that are new, transferred or affected by the
proposed modification.
B. Land Application Site Information:
❑ The status of the land application site with respect to this residuals land application program must be provided in table I. The
status categories and their corresponding codes are as follows:
♦ New (N) + Renewed (R) ♦ Modified (M) ♦ Transferred (T) ♦ Deleted (D)
❑ Attach the following in accordance with each status code:
Status Code
Required Item
N
R
T
M
County Board
Notification. doc
Land Owner
Agreement
(If applicable)
Setback Waiver
Agreement
An updated vicinity/setback map in accordance with the "Map Guidance
for Residuals Land Application .Perniits-
✓
✓
A soils and agronomic evaluation in accordance with the "Soil „Scientist
✓
Evaivati_0n._Pol.i.cy"
INSTRUCTIONS FOR FORM: LASC 06-16 Page] of3

An updated accounting of the land application site's cumulative
I
I
pollutant loading rates (CPLRs)
-:1D
Status Code
Required Item
N
R
T
M
For previously permitted sites without a soil series name indicated in the
Attachment B, submit County Soil Survey Map (or equivalent) clearly
indicate the location of the land application site and in accordance with
the soil map requirements in the "Soil Scientist Evaluation Poky"
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 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 I l-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: httv://deq.ne.gov/about/divisions/water-
resou rces/p tannin 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:
http://deq.nc.gov/contact/rional-off ices
❑ 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).
1 Determine the names of all the closest down slope surface waters from the project site. For unnamed tributaries, see
Table l: Unnamed Tributaries Entering Other States or for Specific Basin Areas. Label any unnamed tributaries as
"UT to stream name" as the waterbody name.
Open the link htt a/de .nc. ovlabout/division s/water-resources/ Ian nin lclassification-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
].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 1S 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
I. Use the Clickable basin map to hydrologically sorted list report.
2. Click on the approximate project location to bring up the hydrologically sorted list.
3. Locate the name of the identified waterbody (from General Directions) on the list.
4. For multiple listings of the same waterbody name in the report, select and verify the location description. The term
"source" in the description means the beginning of the waterbody segment (most upstream point).
5. Record all Basins, Stream Index Numbers and Classifications applicable to the project.
❑ Notes on index number and unnamed streams:
Unnamed Streams 15A NCAC 02B .03010).
❑ 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 I, 1986, any newly created areas of tidal saltwater which are connected to Class SA waters by
approved dredging projects will be classified "SC" unless case -by -case reclassification proceedings are conducted.
❑ The following river basins have different policies for unnamed streams entering other states or for specific areas of the
basin:
Unnamed Tributaries Entering Other States or for Specific Basin Areas
Hiwassee River Basin
Streams entering Georgia or Tennessee shall be classified "C Tr,"
Little Tennesse River
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
_
French Broad River
Streams entering Tennessee will be classified "B."
Basin
Watauga River Basin
Streams entering the State of Tennessee are classified "C."
Broad River Basin
Streams entering South Carolina are classified "C."
New River Basin
Streams entering the State of Tennessee are classified "C."
Catawba River Basin
Streams entering South Carolina are classified "C."
Yadkin -Pee Dee River
Streams entering Virginia are classified "C," and such streams entering South Carolina are
Basin
classified "C."
Lumber River Basin
Streams entering 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."
Chowan River Basin
Streams entering Virginia 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."
Pas uotank River Basin
All drainage canals not noted in the schedule are classified "C."
INSTRUCTIONS FOR FORM: LASC 06-16 Page 3 of 3

LAND APPLICATION SITE CERTIFICATION
Applicant's name: City of Belmont
Land application sites currently certified: 82.3 net acres and Total to be certified: 82.3 net acres.
I. LAND APPLICATION SITE INFORMATION (See Instruction B):
Status
Code
Site/Field
ID
Landowners
� (?
Lessees or Operator(s)
(1
Net Acres
Count Y
Crop(s) s
PO
Predominant Soil
Series Name n
Mapping Unit
or Re Slope'
p P`
R
BT 6-1
Tony Jones
27.0
Lincoln
Fescue
Cecil
CeB2
R
BT 6-3
Tony Jones
12.9
Lincoln
Fescue
Cecil
CeB2
R
BT 9-1
Thomas "Tom" Warren
42.4
Gaston
Fescue
Cecil
CeB2
N
N
N
N
A Status Code for land application sites are: ♦ N (New) ♦ R (Renewed) ♦ M (Modified) ♦ T (Transferred) ♦ D (Deleted)
b Soil Series Name (i.e. Appling. Cecil. etc.)
Mapping Unit must be consistent with those used in the County Soil Survey (i.e. for a 2-8% slope Cecil in Anson County the mapping unit is CeB2)
II. WATERBODY AND CLASSIFICATIONS INFORMATION (See Instruction C):
Site/Field ID
Latitude
Longitude
Location
Datum
Location Method Code
Location Accuracy
Waterbody Subbasin and
Stream Index No.
Current and Proposed
Class
BT 6-1
35.404747
81.032833
NAD 83
GPS
Nearest Second
Killian Creek 1 l-1 19-2-(4)
WS-IV
WS-1V
BT 6-3
35.405989
-81.039175
NAD 83
GPS
Nearest Second
Killian Creek 1 1-1 19-2-(4)
WS-IV
WS-1V
BT 9-1
35.390806
-81.955247
NAD 83
GPS
Nearest Second
Leppers Creek 11-1 I9-1-(12)
WS-IV
WS-1V
NAD 83
ADD
Nearest Second
0
0 «
NAD 83
ADD
Nearest Second
NAD 83
ADD
Nearest Second
o
J:0
NAD 83
ADD
Nearest Second
NAD 83
ADD
Nearest Second
Note: Please keep the site information (I.) and waterbody information (11.) of the same field on the same page.
FORM: LASC 06-16
Page I

Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02T .1100 — LANDOWNER 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 .l 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) (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)
BT 6-1
no
Fescue
Animal Feed
BT 6-3
no
Fescue
Animal Feed
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
FORM: LOA 06-16 Page 1 of 3

1. STIPULATIONS:
1. The landowner or his representative shall not enter into any additional residuals application contracts or agreements with another permitted
entity for the 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
he 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. ]'he 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 he 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 Perm ittec 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 am 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:
I . Appropriate measures must be taken by the Pennittee 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 forgrazing 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 orthe 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. "furf grown on land where residuals are applied shall not he harvested for a 12-month period following a residuals land application event.
III.ALTLRNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 021., .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;
❑ A re -defined compiiance 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 fields) 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 1 have read this Agreement,
understand the stipulations, restrictions, alternatives for water supply wells inside the compliance boundary, acknowledgement of
tield transfer, and do hereby grant permission to the Permittee to land apply residuals to the land application site(s) as specified
herein.
Landowner name: _ Tony Jones - .
Address: 1418 Nature Preserye_Tr"c
CitN : _ Denver _ State: — NC �. Zip: 28037
Phone: __ __ E-mail address:
Signature:
I -
NORTH CAROLINA,
COUNTY
Date:
I, the undersigned Notary Public do hereby certify that _Tog%%A 31PnC —
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official seal this the
day of 0 t .t ft% 1� f
Signature and seal:
My Commissioneap' s:
1_&ssee's/operator's Certification:
If)
Zi,--
1
"UGr
Y Pubiic
VOWS county.
1yICARtO�-�sv`'
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.
Signin,o official name: Adrian •Iler. Cit_Manager
Signature: ' -e i� Date:
12/10/20
FORM: LOA 06-16 Page 3 of 3

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 copies of the application and
suj)j2ortin2 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 .1 100. 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: __- City of Belmont
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
(yeslno)
Land Use or
Cropping Patterns
Intended Use of Crops
p
Residuals Source
(optional)
Special note
(no-tililover-seed/
pasture)
BT 9-1
no
Fescue
Animal Feed
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, the use of the land application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of the Division's permit for the residuals land application program and
shall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittee agree to abide with the following restrictions and
stipulations until such time as written notification, given 30 calendar days in advance, modifies or cancels this Agreement.
FORM: LOA 06-16 Page 1 of 3

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 NCDF.NR-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 ne+% 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. [f 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 pi -I of the soil, residuals and lime mixture is suitable for the
specified crop.
9. The landowner or his representative and the Permittee will agree on residuals application rates and schedules based on crop patterns. results of
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:
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-dav 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 021-.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 boundan- is needed for field(s) ID:
(Please include the rationale for the requested re -location of the compliance boundary anti attach a map showing the newly proposed compliance
boundary to the application package)
® A re -defined compliance boundary is not needed for this site.
1V. 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. helshe 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')

I,andowner's Certification:
certify that i am a deeded landowner of the above -referenced land application sitc(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 wise of the land application site(s) on behalf of the
deeded landowners. 1 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: —_ Thomas Warren
Address: 1401 Alexis Lucia Road -- �—
City: _ J Stan lev State:.._ NC - Zip: — 28164 — .
Phone: —__ _._ — �- _� E-mail address: —,
Signature: Date:.._ 121
- ! �~ `. _ — --
NORTH CAROLINA, �- va�Q� .� COUNTY
I, the undersigned Notary Public do hereby certify that j haow Weirf Y'%
personally appeared before me this day and acknowledged the due execution of the forgoing instrument.
WITNESS my hand and official sea] this the l��✓ ��►ttttttru,r/
` 'L Ry
t,*M1b-t v -
day of
Signature and seal: Not --�
--- - IIk9$ C t!c
o
My commission expir
Lessee's/Operator's Certification:
CAROL��P
r1rrtttnttt+��
certify that t have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee,'operator name:
Address:._ --.------
City:
State
Phone: _ .._....._ F-mail address: _
Signature:
Permittee's Certification:
Date:
Lip: ____
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: _-_- Adrian . it Cit Manager
' f Date: 12/10/20
Signature: ,4 --
7��
—
FORM: LOA 06-16 Page 3 of 3

MAPS

U.S. Biosolids, Inc.- Jones Tract - 6-01 & 6-03 N
Jones, Tony / F
5
0 500 1,000 1,500 21000 f#
Parcel: 3691304282 1 1 1 1
Lincoln, NC Produced: November, 2020
35.407356,-81,038923 North Carolina State Plane, NAD83 Created bv: Joseoh ]arvis