WQ0006984_Correspondence_20210601

ROY COOPER
Governor
DIONNE DELLI-GATTI
Secretary
S. DANIEL SMITH
Director
RETURN RECEIPT REQUESTED
EVERETTE J. OWENS — PLANT MANAGER
SOUTH FORK INDUSTRIES, INC.
POST OFFICE BOX 742
MAIDEN, NORTH CAROLINA-286500742
Dear Mr. Owens:
NORTH CAROLINA
Environmental Quality
June 1, 2021
Subject: Notice of Field Transfer
Permit No. WQ0006984
South Fork Industries RLAP
Residuals Management System
Catawba County
The Division of Water Resources has received and approved a request to transfer the fields listed
below from the subject permit to Permit No. WQ0016247. Attached
are copies of the Land Owner Agreements authorizing this transfer.
Land Owner
Field / Site
County
Acres
Jarret, James O.; Heirs of c/o Jarrett, Ottman
NC-LT-35-01
Lincoln
35.4
Lutz, Dennis Edwin
NC-CA-06-01
Catawba
16.8
Lutz, Dennis Edwin
NC-CA-06-02
Catawba
13.3
Neill Properties LLC
NC-CA-06-03
Catawba
19.6
Please be advised that as of June 1, 2021, the South Fork Industries, Inc. shall not land apply
residuals to the fields listed above. Doing so shall be a violation of G.S. 143-215.1, and may subject
the South Fork Industries, Inc. to appropriate enforcement actions pursuant to G.S. 143-215.6A-6C.
Civil penalties of up to $25,000 per day per violation may be assessed.
Since the subject fields are no longer part of Permit No. WQ0006984, you may submit a permit
modification request to modify the Attachment B, or you may elect to modify the Attachment B during the
permit renewal process.
D E Q�� North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11617 Mail Service Center I Raleigh, North Carolina 27699-1617
NORTH CAROLINA
newhneM or 919.707.9000

Page 2 of 2
If you need additional information regarding this notice, please contact
Erick Saunders at [phone] or [e-mail].
Sincerely,
Nathaniel D. Thornburg, Branch Chi f
Division of Water Resources
cc: Mooresville Regional Office, Water Quality Regional Operations Section (Electronic Copy)
Laserfiche File (Electronic Copy)

State of North Carolina
DWR Department of Environment and Natural Resources
Division of Water Resources
Division of %yater Resources LAND OWNER AGREEMENT
FORM: LOA 06-I6
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking [lie provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of (lie required items will lead to additional processing for Permit application. Unless Otherwise noted the A licant shall siibmit one on pand review time for the
inal and two co ics of the a time
and
supporting documentation
For more information, visit the Water Quality Perinilling Section's Novi-Disclrar a Pet stfttfn Urtft
General — This document is an agreement between the Applicant and land owner(s) of residuals receiving sites for land application of
Class I3 residuals (may include water treatment plant or other type residuals) in accordance with 15A NCAC 02T A100, 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. Lan Owner Agreement (FORM: LOA 46-16):
Submit the completed and appropriately executed Residuals Source Certification FORM: -
16) make any unauthorized content changes to this form. Io 0
f necessary for clarity or due to space restriGtio restrictions, attachmase ents the
it t
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.
.PT'�A copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEKENT TOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
file undersigned [andowner or his representative hereby permits:
Applicant's name: �1.111/n L/Ar v
hereinafter
application
Agreement:
referred to as the Permittee, to land apply residuals from the following facility(ies) onto the following land
site(s) (i.e., see attached setback maps) in accordance with (he stipulations and restrictions as givers in this
Site/Field Ili Lease band Use or
(yes/no) Cropping Patterns
Residuals Sonrce special note
Intended Use of Crops {ol�tion{no-tillfover-seed/
alJ
pasture)
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittee receives, in consideration, (lie use of the laud application site(s) described above for the disposal of the residuals.
This Agreement shall remain in effect for the length of (lie 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 sueh time as ► ritten notification, given 30 calendar days in advance, modifies or cancels this Agreement.
FORM: LOA 06-16
page: I of 3

-STIPULATIONS:
I. The landowner or his representative shall not enter into any additional residuals application contracts or agrcernents with anather permitted
entity for the sile(s) specified by this Agreement.
2. Sbolt Id [he landowner or his representative lease or otherwise permit the use of the land application sites) to a third party, the landowncr shall
be responsible to ensure that the third party agrees and corn p[ics with the terms and conditions of this Agreement.
3• The landowner or his representative shall adhere to (lie provisions of this Agreement until a]1 of time site restrictions (wider Section TI) are met.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-1JWR, Non -Discharge IerSection Unit, met.
Mail Service Center, Raleigh, NC 27699-1636.1636
5. The Permittee must request and obtain a permit modification from the Division pri landaor to a transfer of the land application site(s) to a new
land application site(s). In addition, the current landowner shall give a notice to the new landowncr that gives full details of the residuals applied at the
6, The Perm ittee has provided the [an down cr or his representative with itiform ati[mn and Bala concerning time residuals land application program,
including an analysis of constituents of the residuals, residuals application me[hods, schedules for typical cropping patterns, a description of
Olt equipment used by the Permittee.
7. The Perim ittee will pro vitic the land owner or his representative with a copy of the residuals permit prior to cammencemetmt of any residuals
land application event and a copy of the results of each soil analysis.
8. IFthc soil pH of the land application si[e(s) is riot maintained at 6.0 ar greater, sufficient amounts of lime shall be applied to achieve a final
soil PI1 of at feast 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 [an downer or his representative and the Perrittee 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 itIce with inrormation regarding the Amount and analysis of other sources of
nutrients (e.g., ferlilixer, unregulated animal waste, etc.) that have been applied to the land application site(s).
1 I. The landowner orhis representative will
the laird application
inform the Permittee orally revisions or modifications to time intended use and cropping patterns for
on site(s) prior to eaell planting season to enable the Permiltee 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 [he [and application site(s) by [lie Perm iltee, the landowner, or
his representative prior to and during a residuals (and 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 properly, prcmises, or place on or related to the land application sites) at any reasonable tine far 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 itnder /lie terms and conditions of the permit; (ake necessary Ieachate, surface Water, grotmdwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
11. RESTIZICTIONS:
L Appropriate measures must be taken by the Permittee and/or the landowner or his representative to control public access to time land
application sites) during active use and For the 12-month period following a residuals larmd application event. Such controls may include the
pasting of signs that indicate the activities being conducted at the ]and application site(s).
2. Ali imals shall not be grazed on the land application site(s) for it 30-day period Following a residuals land application event. Land application
sites that are to be used for grazing sliall have Fencing that will be used to prevent access during these periods after sucli residuals land
application events,
3. food crops, feed crops, and fiber crops shall not be harvested For a 30-day period following a residuals ]and 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-
rnotith period following a residuals [and application event.
5. Food crops with harvested parts below the surface of time land shall not be harvested for a 20-month period following a residuals land
application event when the residuals remain orm the land surface for four months or longer prior to incorporation into the soil.
E rood crops with Iarvested parts below the surface of the land steal[ not be harvested for a 38-nmonth period following a residuals land
application event mvhen 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 steal] not be harvested for a 12-month period following a residuals land application event.
III, ALTERNATIV Es FOIL WATER SUPPLY WFLLS INSIDE THE COMTLIANCE DOUNIDARY: (please cheek one)
15A NCAC 021, ,0I07(d) prohibits water supply wells within the compliance boundary, However, I5A ItiICAC 02f' 0I 5 h allows the
compliance boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of time compliance
boundary provided the groundwater standards can be met at [lie newly -established compliance boundary. Please mark one of the following;
❑ A rc-defined compliance boundary is needed for field(s) ID:
(Please include the rationale for the requested re -location of time compliance boundary and attach a neap showing the newly proposed
mpliance boundary to the application package)
Jh► re -defined compliance boundary is not needed for this site,
IV. OWLEDGEMENT OI< FIELD TRANSFER: (ir needed)
7land application field(s) [D:
residuals land application program; Pemit Number WQ: 0 o0 is currently permitted under another
agreement, he/she is rcquesti that the field(s) be� rc� ovfd from the yy��eeviQuslyr permitted ree land siduals landwner bappl caQoneprogram athat nd transferred
ing this
intointo the new program; n ly �,IlSTlr y �l
�+�n
(Nance of the new prilgramn)
FORM: L.OA 06-16
Page 2 of 3

Landowner's Certification;
1 certify that I ann 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 ant 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 rnrmicipality, contractor, or other permitted entity, Furthennore, ]certify that I have read this Agreement,
understand the stipulations, restrictions, alternatives for water supply wells inside the evmpeante boundary, rd thisacknowledgement
t,
field transfer, and do hereby grant Permission to (lie Permittee to land apply residuals to the land application sitc(s) as specified
hercin-
Landowner naive: ❑+ ��
Address:
city: )--•'nC-rn�VIA—
Zip.
r Zip: �-
Phone: 9 c�- "� F'7`"�� �j 2-mail address:
Signature: c -
r Date:
NORTH CAROLINA, L, ir,r „r T
CO UIN I Y 4
1, tine undersignett Notary public do hereby certify that 0-40X
personally appeared before me this clay and acknowledged the due execution of the forgoing instrument
WITNESS my hand and official sea] this the ',� 3" r-
day of CG
Signature and seal:
1-1/1 VX'41—
My commission expires: DC-1 2 r
z
_
Lessee's/`Operator's Certifirhliort:
20
I certify that I have read this Agreetnxent and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name:
Address, -
City:
Phone:
Signature:
Perrnittee's Certifleation:
State:
E-mail address:
Date:
Zip.
I certify that I have read this AgreetnenI and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name: �jL! }- fL
Signature:
Date:
FORM: LOA 06-16
Page 3 of 3

State of North Carolina
DMR
Department of Environment an(! Natural Resources
Division of Water Resources
Division of Water Resources
LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use the following instructions as a checklist in order to ensure all required items are submitted. Adherence to these
instructions and checking the provided boxes will help produce a quicker review time and reduce the amount of additional
information requested. Failure to submit all of the required items will lead to additional processing and review time for the
permit application. Unless otherwise noted the A licant shall submit one nri final and two copies of the application and
supporting documentation
Far more information, visit the Water Quality Permitting Section's Non -Discharge Permitting Clint
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) ui accordance with 15A NCAC 02T .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06.16).
Unless otherwise noted, the Applicant shall suhmiI one original and two copies of the application and supporting documentation listed
below.
A. La►yd Owner Agreement (FORM: LOA 06-16);
VSubmit the completed and appropriately executed Residuals Source Certification (FORM. LASC 06-16) form. Please do not
make any unauthorized content changes to this form. if necessary for clarity or due to space restrictions, attaclunents to the
{pplicahoil may be made, as long as the attachments are numbered to correspond to the section and iten) to which they refer.
Prepare a separate agreement for each set of land application sites that are owned or operated by an entity other than the
Applicant.
copy of the completed and appropriately executed agreement must be provided to the landowner and the lessee/operator.
AGREEMENT FOR THE LAND APPLICATION OF RESIDUALS TO PRIVATELY OWNED LAND
fhe undersigned landowner or his representative hereby permits:
Applicant's name:�_�t 3 .iron
hereinafter referred to as the Permittee, to land apply residuals from the following facility(ics) onto the following land
application Ate(s) (i.e., see attached setback maps) in accordance with the stipulations and restrictions as given in this
Agreement:
Site/Field ID
Cease
(yes/no)
land Use or
Cropping Patterns
Intended Use of Crops
Residuals Source
(Optional)
Special note
(no-tilllover-seed!
pasture)
'`
The landowner or his representative receives, in consideration, full use of the nutrient value of the applied residuals while the
Permittec receives, in consideration, the use of the land application site(s) deseribed 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
,hall be renewed each time this permit is renewed.
The undersigned landowner or his representative and the Permittec 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] of3

I. STIPULATIONS:
1. The landowner at his representative shall not enter into any additional residuals application contracts or agreements wilh another permitted
entity for the site 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 leis representative s1taII adhere to the provisions of this Agreement until all of the site restrictions (under Section II) are iltet.
4_ Notification of cancellation of this Agreement shall be immediately forwarded to NCI3ENR-DWR, Non -Discharge Permitting Unit, 1636
Mail Service Center, Raleigh, NC 27699-1636.
5. The Permittee most request and obtain a permit modification from the Division prior to a transfer of the land application sitc(s) to a new
landowner. In addition, the current landowner shall give a notice to the new landowner that gives full details of the residuals applied at the
land application site(s).
6. The Perm ittee has provided the landowner or his representative ►vith information and data con ccming the residuals land application program,
including an analysis of constituents of the residuals, residuals application in elItods, schedules for typical cropping pall enis, a description of
the equipment used by the Permittee.
7. The Pertnillee will provide the landowner or his representative: tivith 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 pit of the land application sitc(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 pt 1 of the soil, residuals and lime mixture is suitable for
the specified crop.
9. The landowner or his representative and the Penn ittee will agree oil residuals application rates and schedules based on crop pal terins, results of
soil samples, and the permitted application limits.
10. The landowner or leis representative will provide the lllcrmittee with information regarding the amount and analysis of other sources Df
nutrients (e.g., fertilizer, unregulated animal waste, etc.) that have been applied to the land application site(s).
11. The landowner or his representative ►vitI inform the Perm ittec of any revisions or modifications to the intended use and cropping palterns for
the land application sitc(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 she(s) by the Permittce, the landowner, or
his representative prior to and during a residuals land application event.
13. The landowner or his representative hereby authorizes the Penmittee, 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 tune for the purpose of determining
compliance with (lie permit; establish monitoring facilities on or near the land application sitc(s) as required by the permit; copy any records
that must be kept under the terms and conditions of the permit; take necessary Ieach ate, surrare wager, groundwater, or soli samples during the
tern of, and 12 months after termination of, this Agreement.
II. RESTRICTIONS:
1. Appropriate measures most be taken by (lie 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 it 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. Ali ima]s shall not be grazed on the land application sites) for a 30-day period following a residuals land application event_ land application
sites that are to be used for grazing sliall 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 riot 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 refrain o» the land surface for less than four months prior to incorporalioil into the soil.
7. Turf grown on laird where residuals are applied shall not be harvested for a 12-month period following a residuals land application event.
III. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 02L .0107(d) prohibits water supply wells within the compliance boundary. However, 15A NCAC_42T-.0101(h] allows Ilse
compliance boundary to he placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance
boundary provided (he groundwater standards can be met at the newly -established compliance boundary. Please mark one of the following;
❑ A re -defined coin pIiall cc boundary is needed far field(s) ID:
(Please include the rationale for the requested re -location of the compliance boundary and attach a map showing the newly proposed
oinpIiance boundary to ttic application package)
A re -defined compliance boundary is not needed for this site.
IV, ACOWLEDGr,,MFNT OF FIELD TRA SF1ER: {jf needed)
The land application fields) ID: C
residuals land application program; Permit Number WQ; Ot>
agreement, he/she is requestin that the field(s) be removed from
into the new program; !94 n;s, rn WIFIS;+reeL,-
. is currently permitted under another
. The land owner hereby acknowledge that by signing this
Dusty, permitted r si i is land a plication program and transferred
�- asp 7
(Name of the ne►v program)
FORM: LOA 06-16 Page 2 oF3

Landowner's Certification:
I ceili£y that I am a deeded landowner of the above -referenced land application site(s) and am authorized to make decisions
regarding the use of the land application sites) on behalf of other deeded landowners OR that I am otherwise authorized, through
a power of attorney or other legal delegation, to make decisions regarding the use of the land application site(s) on behalf of the
deeded landowners. I certify that the above -referenced land application site(s) are not included in any waste disposal contract or
agreement with anotlier municipality, contractor, or other permitted entity. Pirrtherntore, I certify that I have read this Agreement,
understand the stipulations, restrictions, alternatives for water supply wells inside the compliance boundary, acknowledgement of
field transfer, and do hereby grant permission to the Permittee to land apply residuals to the land application site(s) as specified
herein.
Landowner name: a-N,
Address: Z S tea.. t W,
City: U13C State: :Lip: A
Phone: 2.% " ��7 ' �� 5 E-mail address:
Signature: ° _ _ Date: IWOWD �-
NORTH CAROLINA, _�i o moo. COUNTY
I, the undersigned Notary Public do hereby certify that {t •�5 u �"�
personally appeared before one this day and acknowledged the due execution of the forgoing instrument.
P Y Pl Y g g g A i�Zi
WITNESS nuy hand and�;ofricial seal this the ►�� d- -�0.
IS M
day of V L,20
Signature and seal: =C]
{� v�
My commission expires: VG `� 0 •��I�I,,��2,
11l111
Lessee's/Operator's Certification:
1 certify that I have read (his Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Lessee/operator name:
Address:
City:
Phone;
Signature:
Permittec's Certification:
State:
E-mail address:
I certify that I have read this Agreement and do hereby agree
Signing official name;
Signature;
2M
Date:
abide by the stipulations and restrictions as specified herein.
el\
Date: I / I ? j Z
FORM: I OA 06-16 Page 3 of 3

State of North Carolina
Department of Environmclit and Natural Resources
❑ivisiou of Water Resources
Division of Water Resources LAND OWNER AGREEMENT
FORM: LOA 06-16
Please use (fie 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 tune for the
permit application. Unless otherwise noted, the Applicant shall submit one original and two copies ofthe application and
supporting documentation
For more injbrination, visit the Water Quality Permitting Section's Non -Discharge Fei-enitift Un
General — This document is an agreement between the Applicant and ]and owners) of residuals receiving sites for land application of
Class B residuals (may include water' treatment plant or other type residuals) in accordance with 15A NCAC 02T .1100. Do not
submit this agreement for review without a corresponding application form (FORM: RLAP 06-16).
Unless otherwise noted, [lie Applicant shall submit one Original and two copies of the application and supporting documentation listed
below,
A. Lan wner Agreement (FORM, LOA 06-16):
Submit the completed and appropriately executed Residuals Source Certification (DORM: LASC 06-16) form. Please do not
make any unauthorized content changes to this form. If necessary for clarity or due to space restrictions, attaclunents to the
plication 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
plicant.
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
fire undersigned landowner or his representative hereby permits:
Applicant's name: �.A,;�r; �,� ;�ir� _ Pei �,j—
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 I'atterus
Intended Use of Crops
Residuals Source
(optional)
Special note
(no-till/over-seed/
pasture)
9-ate
r-e, s
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 (lie 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
;hall 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 v ith another permitted
catiry for the site(s) specified by this Agreement.
2. Should the landowner or his representative lease or otherwise perinit the use of the land application site(s) to a third party, the landowner shall
be responsible to ensure tliat 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 restrietinns (under Section I I) are niet.
4. Notification of cancellation of this Agreement shall be immediately forwarded to NCDENR-DWR. Non -Discharge Permitting Unit, 1636
Mail Service Center, Raleigh, NC 27699-1636.
5. 'i'he Pennittee must request and obtain a perinit modification front the Division prior to a transfer of the land application sitc(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 file
land application site(s).
6. 'The Pemtittee 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 cquipment used by the Permittee.
7. The Perm ilice will provide the landowner or his representative with a copy of the residuals pennit prior to co mill encement 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 sites) is not maintained at 6.0 or greater, sufficient amounts of lime shall be applied to achieve a anal
soil pI4 of at least 6.0, unless an agronomist provides information indicating that the pl I of the sail, residuals and lime mixture is suitab Ic for
the specified crop.
9. The landowner or his representative and the Perm iltee will ngrec 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 Pen tittee with information regarding the arnouat and analysis of other sources of
nutrients (a.g., fertiIirer, unregulated animal waste, etc.) that have been applied to the land application sile(s).
11. The landowner or his representative will infonn the Permiltee of any revisions or modifications to the intended use and cropping patterns for
the land application sites) prior to each planting season to enable the Pennittee to amend this Agreement and schedule residuals land
application events at appropriate periods.
12. Specific residuals land application area boundaries shall be clearly marked on the land application sites) by the Perini Itee, the landowner, or
Iiis representative prior to and during a residuals land application event.
13. The landowner or his representative hereby aulhori7es the Permiltee, 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 61' determining
compliance with the pennit; establish monitoring facilities on or near the lased application sites) as required by the permit; cgpy any records
that must be kept under the terns and conditions of the pen nit; take nee essary leachate, surface water, groundwater, or soil samples during the
term of, and 12 months after termination of, this Agreement.
11. RESTRICTIONS:
1. Appropriate measures must be taken by the Permitee and/or the landowner or his representative to control public access to the land
application sites) 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 bei rig conducted at the land application site(s).
2. Animals shall not be grazed on the land application sile(s) for a 30-day period following a residuals Iand 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.
S. 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 inon ths or longer prior to incorporation into the soil,
6. Food crops with harvested parts below the surface of the land shall not be harvested ror 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 Sand where residuals are applied shall not be harvested for a 12-month period following a residuals land application event.
Hf. ALTERNATIVES FOR WATER SUPPLY WELLS INSIDE THE COMPLIANCE BOUNDARY: (please check one)
15A NCAC 021, .0107(d) prohibits water supply wells within the compliance bottndai),. 1-lowever, 15A NCAC 02T .0105(hl allows the
compliance boundary to be placed closer to the waste disposal area, such that the water supply well is situated outside of the compliance
boundary provided the groundwater standards can be met at the newly -established compliance boundary. Please mark one of the following;
❑ A re -defined compliance boundary is needed for field(s) ID: _
(Please include the rationale for the requested re -location
compliance boundary to the application package)
[� A rc-defined compliance boundary is not needed for this site.
of the compliance boundary and altach a map showing the newly proposed
IV. AC NOWLEDGEMENT OF FIELD TRA SFER: f needed)
fhe land application freld(s) ID: is currently permitted under another
residuals land application program; Permit Number WQ: 000(r rr, _ _. 'fhe land owner hereby acknowledge that by signing this
agreement. he/she is requestin that the field(s) be rrmaved�arr}ihe p� iously permitted residuals land application program and transferred
into the new program; -►.n ro S w i. _w.n 1./-0
(Name of the new program)
FORM: LOA 06-16 Page 2 of 3

Landowner's Certification;
1. certify that I am a deeded landowner of the above -referenced land application site(s) and am authorized to make decisions
regarding tiie use of the land application site(s) on behalf of other deeded landowners OR that I am ❑therwise authorized, through
a power of attorney or other legal delegation, to make decisions regarding the use of the land application sites) 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 mutiicipality, contractor, or other permitted entity. furthermore, I cei3ify 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 Permitice to land apply residuals to the land application site(s) as specified
herein.
Landowner name: Wo ' (( f a S I Ly
Address: a 1'3'0 rs g
City: , [�„ State:
Phone: I (o77 E-mail address:
Signature: J
NORTH CARD , C41 COUNTY
1, the undersigned Notary Public do hereby certify that
zip: a
aLt U n1 C_
Date: / 4— j D• 2-0
personally appeared before we this day and acknowledged the due execution of the forgoing instrument
WITNESS my hand and officialsealthis the
day of � _
Signature and Seal: AW
My commission expires: a-
Lessee's/operator's Certification:
.20
kk
tt 4LL1
"'" ;
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:
&mail address:
Date:
Zip:
I certify that 1 have read this Agreement and do hereby agree to abide by the stipulations and restrictions as specified herein.
Signing official name:
Signature:
Date:
FORM: LOA 06-16 Page 3 of