Online Land Application Forms for 02H Permits 130801

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*** Please note that adjustments may have to be made to your printers properties when printing***
Instructions for Proper Submittal
Complete all forms that are required for your Land Application Program's submittal of an Annual Land Application Report. If the report is incomplete it will be sent back.
The forms must be filled out correctly and completely or the report will be sent back.
The state supplied forms ( ACF, DMSD, RSSF, RSSF-B, FSF, MFLSF, and PVRF ) are the only approved forms that may be used for submittal of the Annual Land Application Report. If other
unapproved adaptations are used the report will be sent back. If you have any questions on whether or not an adaptation is appropriate please contact the Land Application Unit.
The previous state forms may be used for the Annual Land Application Report for calendar year 2002. All Annual Land Application Reports submitted for calendar years after 2002 must use
the updated forms or the report will be sent back.
These forms can be filled out electronically or by hand as with the Non-Discharge Spray Forms. If filling out electronically fill out the forms in the order that they are presented.
The ACF, DMSDF, RSSF, RSSF-B, and PVRF have been changed aesthetically but require the same information to be submitted as in the previous forms.
The FRS, has been changed to include new information to be submitted. Please review carefully. If you have any questions please contact the Land Application Unit.
The MFLSF is a newly created form to calculate the equations needed to be performed on the FSF form. Please review carefully. If you have any questions please contact the Land Application
Unit.

ANNUAL LAND APPLICATION CERTIFICATION FORM
Permit#:
Facility Name (as shown on permit):
Land Application Operator:
Land application of residual solids as allowed by the permit occurred during the past calendar year?
Yes
generated but not land applied, please attach an explanation on how the residuals were handled.
Part A:
Total number of application fields in permit:
Total number of fields land application occurred during the year:
Total amount of dry tons applied during the year for all application sites:
Total number of acres land application occurred during the year:
Part B:
Facility was compliant during calendar year
(including but not limited to items 1-12 below) issued by the Division of Water Resources.
If no please, provide a written description why the facility was not compliant, the dates, and explain
corrective action taken.
1. Only residuals approved for this permit were applied to the permitted sites.
2. Soil pH was adjusted as specified in the permit and lime was applied (if needed) to achieve a soil pH of at
least 6.0 or the limit specified in the permit.
3. Annual soils analysis were performed on each site receiving residuals during the past calendar year and three
(3) copies of laboratory results are attached.
4. Annual TCLP analysis was performed and three (3) copies of certified laboratory results are attached.
5. All other monitoring was performed in accordance with the permit and reported during the year as required
and three (3) copies of certified laboratory results are attached.
6. The facility did not exceed any of the Pollutant Concentration Limits in Table 1 of 40 CFR Part 503.13 or the
Pollutant Loading Rates in Table 2 of 40 CFR part 503.13 (applicable to 40 CFR Part 503 regulated facilities).
7. All general requirements in 40 CFR Part 503.12 and management practices in 40 CFR Part 503.14 were
complied with (applicable to 40 CFR Part 503 regulated facilities).
8. All operations and maintenance requirements in the permit were complied with or, in the case of a deviation,
prior authorization was received from the Division of Water Resources.
9. No contravention of Ground Water Quality Standards occurred at a monitoring well or explanations of
violations are attached to include appropriate actions and remediations.
10. Vegetative cover as specified in the permit was maintained on this site and the crops grown were removed
in accordance with the crop management plan.
11. No runoff of residuals from the application sites onto adjacent property or nearby surface waters has occurred.
12. All buffer requirements as specified on the permit were maintained during each application of residuals.
"I certify, under penalty of law, that the above information is, to the best of my knowledge and belief, true,
accurate, and complete. I am aware that there are significant penalties for submitting false information,
including the possibility of fines and imprisonment for knowing violations."
Permittee Name and Title (type or print)
________________________________
Signature of Preparer*
(if different from Permittee)
* Preparer is defined in 40 CFR Part 503.9 (r)
No If No, skip Part A, and Part B and proceed to the certification. Also, if residuals were
County:
Date
_____________
with all conditions of the land application permit
_____________________________
Signature of Permittee
_____________________________
Signature of Land Applier
(if different from Permittee and Preparer)
Year:
Phone:
Yes
____________
Date
____________
Date
No

ANNUAL DISTRIBUTION AND MARKETING/ SURFACE DISPOSAL CERTIFICATION AND SUMMARY FORM
PERMIT #:
PHONE:
FACILITY TYPE (please check one):
Was the facility in operation during the past calendar year? Yes No
Part A*:
Month
January
February
March
April
May
June
July
August
September
October
November
December
Totals:
Amendment(s) used:
* If more space than given is required, please attach additional information sheet(s).
Part C:
Facility was compliant during calendar year
Division of Water Resources.
1. All monitoring was done in accordance with the permit and reported for the year as required and three (3) copies of certified laboratory results are attached.
2. All operation and maintenance requirements were compiled with or, in the case of a deviation, prior authorization was received from the Division of Water
Resources.
3. No contravention of Ground Water Quality Standards occurred at a monitoring well.
"I certify, under penalty of law, that the above information is, to the best of my knowledge and belief, true, accurate and complete. I am aware
that there are significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations."
____________________________________
Signature of Permittee
Sources(s) (include NPDES # if applicable)
Annual (dry tons):
FACILITY NAME:
COUNTY:
Yes
Volume (dry tons)
Amendment/ Bulking Agent In
0
_________
Date
Surface Disposal (complete Part A (Source(s) and "Residual In" Volume only) and Part C)
Distribution and Marketing (complete Parts A, B, and C)
0
with all conditions of the permit (including but not limited to items 1-3 below) issued by the
No
Residual In
Bulking Agent(s) used:
If No, please provide a written description why the facility was not compliant.
0
___________________________________
Signature of Preparer**
(if different from Permittee) **Preparer is defined in 40 CFR Part 503.9(r)
OPERATOR:
Product Out
0
0
Check box if additional sheet(s) are attached
No If No skip parts A, B, C and certify form below
Part B*:
Recipient Information
Name(s)
Volume (dry tons)
_________
Date
0
Intended use(s)

ANNUAL RESIDUAL SAMPLING SUMMARY FORM
Attach this form to the corresponding Annual Report
Please note that your permit may contain additional parameters to be analyzed than those required to be summarized on this form.
Parameters (mg/kg)
“I certify, under penalty of law, that this document was prepared under my direction or supervision in accordance with a system
designed to assure that qualified personnel properly gathered and evaluated the information submitted. I am aware that there are
significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations.”
____________________________________________
Signature of Preparer
Permit Number:
Facility Name:
NPDES # or WQ#:
WWTP Name:
Residual Analysis Data
Sample or Composite Date
Percent Solids
Arsenic
Cadmium
Chromium
Copper
Lead
Mercury
Molybdenum
Nickel
Selenium
Zinc
Total Phosphorus
TKN
Ammonia-Nitrogen
Nitrate and Nitrite
Laboratory:
___________
Date
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5)

Attach this form to the corresponding Annual Report
Please note that your permit may contain additional parameters to be analyzed than those required to be summarized on this form.
Parameters (mg/kg)
“I certify, under penalty of law, that this document was prepared under my direction or supervision in accordance with a system
designed to assure that qualified personnel properly gathered and evaluated the information submitted. I am aware that there are
significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations.”
____________________________________________
Signature of Preparer
ANNUAL RESIDUAL SAMPLING SUMMARY FORM
Permit Number:
Facility Name:
NPDES # or WQ#:
WWTP Name:
Residual Analysis Data
Sample or Composite Date
Laboratory:
___________
Date
1)
2)
3)
4)
5)

ANNUAL METALS FIELD LOADING SUMMARY FORM*
Attach this form to the corresponding Field Loading Summary Form to be submitted in Annual Report
Facility Name:
Permit #:
Operator:
Acres Used:
Residual Analysis Data (Heavy Metals and Total Phosphorus use mg/kg, % Solids use Raw Percent #):
Sample or Com-posite Date
% Solids
Arsenic
Cadmium
Chromium
Copper
Lead
Mercury
Molyb-denum
Nickel
Selenium
Zinc
Total Phos-phorus
Annual Heavy Metal Field Loadings (Calculated in lbs/acre):
Total DT/Ac./ Yr./Application Event
Arsenic
Cadmium
Chromium
Copper
Lead
Mercury
Molyb-denum
Nickel
Selenium
Zinc
Total Phos-phorus
"I certify, under penalty of law, that this document was prepared under my direction or supervision in
accordance with a system designed to assure that qualified personnel properly gathered and evaluated the
information submitted. I am aware that there are significant penalties for submitting false information,
including the possibility of fines and imprisonment for knowing violations"
______________________________________________
Signature of Land Applier
* See bottom of FSF Form for helpful instructions for this MFLSF Form and the mathematically linked FSF Form
Acres Permitted:
Cation Exchange Capacity (non 503 only):
Owner:
Total Dry Tons Applied (Annual):
Site #:
____________
Date

Field #:
Totals:

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH APPLICATION FIELD.
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Facility Name:
Owner:
Site #:
Date or Month
TOTALS:
Annual lbs/acre
Current Cumulative lbs/ac
Prior Years Cumulative lbs/ac
Permitted C. P. L. R.***
Permit PAN Limit 1st/2nd Crop
“I certify, under penalty of law, that this document was prepared under my direction or supervision in accordance with a system
designed to assure that qualified personnel properly gathered and evaluated the information submitted. I am aware that there are
significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing violations.”
____________________________________________
****
The RSSF Data and the Dry Tons Per Acre are to be entered on the MFLSF Form. The FSF and MFLSF are mathematically linked so this information needs to be entered into the same numbered
column on the MFLSF as is entered on the identically numbered FSF row to properly complete the metals equations. ie. FSF row # 1 to MFLSF column # 1.
Specify
Gal.
Cu.Yd.
Report
Totals
in Gal.
Signature of Land Applier
Totals Per Acre
Field #:
% Solids
Dry Tons Per Acre
As
Operator:
Residual Sources (Summarize)
Cd
Cr
Site Cond. Dry, Wet, Moist
Cu
__________________
Permit #:
Acres Utilized:
Inches Precip.Past 24 Hrs.
Pb
Date
Appli-cation Meth-od*
Hg
Vola-tili-zation Rate**
Mo
*Application Method: S - Surface, IN - Injection, INC - Incorporation
**Volatilization Rate: Surface - 0.5, Injection/Incorporation - 1.0
***C.P.L.R.: Cumulative Pollutant Loading Rate
Miner-ali-zation Rate
Ni
Annual Dry Tons Applied:
Cation Exchange Capacity (non 503):
TKN
Se
Acres Permitted:
Ammo-nia- Ni-trogen
Zn
Ni-trate and Nitrite
P
PAN 1
PAN 1
PAN 2
PAN 2
Must Select Crop 1 or Crop 2
Crop 1
Lime Applied
Date
Crop 2
lbs/ac
*
*
*
*
1
2
3
4
5
6
7
8
9
10
11
12

ANNUAL PATHOGEN AND VECTOR ATTRACTION REDUCTION FORM
Facility Name:
WWTP Name:
Monitoring Period: From
Pathogen Reduction (40 CFR 503.32) - Please indicate level achieved and alternative performed:
Class A:
If applicable to alternative performed (Class A only) indicate “Process to Further Reduce Pathogens”:
Compost
Beta Ray
Class B:
If applicable to alternative performed (Class B only) indicate “Process to Significantly Reduce Pathogens”:
Lime Stabilization
Anaerobic Digestion
If applicable to alternative performed (Class A or Class B) complete the following monitoring data:
Parameter
Fecal Coliform
Salmonella bacteria (in lieu of fecal coliform)
Vector Attraction Reduction (40 CFR 503.33) - Please indicate option performed:
Option 1
Option 6
No vector attraction reduction options were performed
CERTIFICATION STATEMENT (please check the appropriate statement)
“This determination has been made under my direction and supervision in accordance with the
system designed to ensure that qualified personnel properly gather and evaluate the information
used to determine that the pathogen and vector attraction reduction requirements have been met. I
am aware that there are significant penalties for false certification including fine and imprisonment.”
Preparer Name and Title (type or print)
___________________________________
Signature of Preparer
“I certify, under penalty of law, that the pathogen requirements in 40 CFR 503.32 and the vector
attraction reduction requirement in 40 CFR 503.33 have been met.”
“I certify, under penalty of law, that the pathogen requirements in 40 CFR 503.32 and the vector
attraction reduction requirement in 40 CFR 503.33 have not been met.” (Please note if you check
this statement attach an explanation why you have not met one or both of the requirements.)
Alternative 1
Alternative 4
Heat Drying
Gamma Ray
Alternative 1
Allowable Level in Sludge
2 x 10 to the 6th power MPN per gram of total solids or 2 x 10 to the 6th power CFU per gram of total solids
1000 mpn per gram of total solid (dry weight)
3 MPN per 4 grams total solid (dry weight)
Option 2
Option 7
Air Drying
Pathogen Density
Minimum
Option 3
Option 8
Alternative 2
Alternative 5
Heat Treatment
Pasteurization
Alternative 2
Geo. Mean
________
Date
To
Composting
Maximum
Option 4
Option 9
Land Applier Name and Title (if applicable)(type or print)
______________________________________
Signature of Land Applier (if applicable)
Units
Permit Number:
NPDES Number:
Alternative 3
Alternative 6
Thermophilic
Alternative 3
Number of Excee-dences
Option 5
Option 10
Aerobic Digestion
Frequency of Analysis
Sample Type
Analytical Tech-nique
_______
Date