Online Land Application Forms for 02T Permits 140123

ANNUAL LAND APPLICATION CERTIFICATION FORM
WQ Permit#:
Facility Name (as shown on permit):
Land Application Operator:
Land application of residuals 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 - Residuals Application Summary:
Total number of application fields in the permit:
Total number of fields utilized for land application during the year:
Total amount of dry tons applied during the year for all application sites:
Total number of acres utilizes for land application during the year:
Part B - Annual Compiance Statement:
Facility was compliant during calendar year
(including but not limited to items 1-13 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)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
Part C - Certification:
"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) and 15A NCAC 02T .1102 (26)
Only residuals approved for this permit were applied to the permitted sites.
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.
Annual soils analysis were performed on each site receiving residuals during the past calendar year and three (3) copies of laboratory results are attached.
Annual TCLP analysis (if required) was performed and three (3) copies of certified laboratory results are attached.
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.
The facility did not exceed any of the Pollutant Concentration Limits in 15A NCAC 02T .1105(a) or the Pollutant Loading Rates in 15A NCAC 02T .1105(b) (applicable to 40 CFR Part 503
regulated facilities).
All general requirements in as specified in the Land Application Permit were complied with (applicable to 40 CFR Part 503 regulated facilities).
All monitoring and reporting requirements in 15A NCAC 02T .1111 were complied with (applicable to 40 CFR Part 503 regulated facilities).
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.
No contravention of Ground Water Quality Standards occurred at a monitoring well or explanations of violations are attached to include appropriate actions and remediations.
Vegetative cover was maintained and proper crop management was performed on each site receing residuals, as specified in the permit.
No runoff of residuals from the application sites onto adjacent property or nearby surface waters has occurred.
All buffer requirements as specified on the permit were maintained during each application of residuals.
No
- If No, skip Part A, and Part B and proceed to Part C. 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

CLASS A ANNUAL DISTRIBUTION AND MARKETING/ SURFACE DISPOSAL CERTIFICATION AND SUMMARY FORM
WQ PERMIT #:
PHONE:
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
Total from FORM DMSDF (sup)
Totals:
Amendment(s) used:
* If more space is required, attach additional information sheets (FORM DMSDF (supp)):
Part C:
Facility was compliant during the past calendar year with all conditions of the land application permit (including but not limited to items 1-3 below) issued by the 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
**Preparer is defined in 40 CFR Part 503.9(r) and 15A NCAC 2T .1102 (26)
Sources(s) (include NPDES # if applicable)
Annual (dry tons):
FACILITY NAME:
COUNTY:
FACILITY TYPE (please check one):
Volume (dry tons)
Amendment/ Bulking Agent
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
_________
Date
0
Residual In
Bulking Agent(s) used:
0
___________________________________
Signature of Preparer**
(if different from Permittee)
OPERATOR:
Product Out
0
If No skip parts A, B, C and certify form below
Part B*:
Recipient Information
Name(s)
Yes
No
Volume (dry tons)
Total Number of Form DMSDF (Supp)
If No, Explain in Narritive
_________
Date
Intended use(s)

CLASS A ANNUAL DISTRIBUTION AND MARKETING/ SURFACE DISPOSAL CERTIFICATION AND SUMMARY FORM
Supplemental Information
WQ PERMIT #:
PHONE:
Part A*:
Month
Totals:
Amendment(s) used:
* If more space is required, attach additional information sheets (FORM DMSDF (supp)):
Sources(s) (include NPDES # if applicable)
Annual (dry tons):
FACILITY NAME:
COUNTY:
FACILITY TYPE (please check one):
Volume (dry tons)
Amendment/ Bulking Agent
Surface Disposal (complete Part A - "Month", "Source(s)" and "Residual In" columns only)
Distribution and Marketing (complete Parts A, and B)
0
0
Residual In
Bulking Agent(s) used:
OPERATOR:
Product Out
Part B*:
Recipient Information
Name(s)
Volume (dry tons)
Total Number of Form DMSDF (Supp)
Intended use(s)

ANNUAL RESIDUAL SAMPLING SUMMARY FORM
Please note that your permit may contain additional parameters to be analyzed. The parameters can be reported in FORM RSSF - B
Residual Source WQ # or NPDES #:
Residual Analysis Data
Parameter (mg/kg)
Percent Solids (%)
Arsenic
Cadmium
Copper
Chromium
Lead
Mercury
Molybdenum
Nickel
Selenium
Zinc
Total Phosphorus
TKN
Ammonia-Nitrogen
Nitrate and Nitrite
a For surface disposal facilities the ceiling concentration limits listed in this form are not applicable. Reference the individual permit for metals limits.
“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 *
*Preparer is defined in 40 CFR Part 503.9(r) and 15A NCAC 2T .1102 (26)
WQ Permit Number:
Facility Name:
WWTP Name:
Ceiling Conc. Limit (mg/kg)a
NA
75
85
4300
NA
840
57
75
420
100
7500
NA
NA
NA
NA
Sample or Composite Date
Laboratory:
Date
1)
2)
3)
4)
5)

ANNUAL RESIDUAL SAMPLING SUMMARY FORM - B
Report all sampling analysis results for parameters not listed in FORM RSSF that are part of the WQ permit or were analyzed for over the past calendar year. Use additional forms as
needed.
WQ Permit Number:
Facility Name:
Residual Source NPDES # or WQ#:
WWTP Name:
Residual Analysis Data
Parameter (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 *
*Preparer is defined in 40 CFR Part 503.9(r) and 15A NCAC 2T .1102 (26)
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
Copper
Chromium
Lead
Mercury
Molyb-denum
Nickel
Selenium
Zinc
Total Phos-phorus
Annual Heavy Metal Field Loadings (Calculated in lbs/acre):
Total DT/Ac./ App. Event
Arsenic
Cadmium
Copper
Chromium
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
Acres Permitted:
Cation Exchange Capacity (non 503 only):
Owner:
Total Dry Tons Applied (Annual):
Site #:
____________
Date

Predominant Soil Series:
Field #:
Totals:

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Date or Month
TOTALS:
Annual lbs/acre
Prior Years Cumulative lbs/ac
Current 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.”
Facility Name:
Land Owner:
Operator:
Volume applied (enter one) Solids/ Liquid
Cu. Yds
Signature of Land Applier
Crop 1 Name:
Gallons
% Solids
Volume Applied per Acre
(Dry Tons/Ac)
As
Residual Sources (NPDES #, WQ#, Fert., Animal Waste, etc)
Residuals Applications totals on FORM FSF supp ( attach FORM FSF supp to this form):
Cd
Cu
WQ Permit #:
Annual Dry Tons Applied:
Crop 1 Max. PAN:
Soil Cond. (Dry, Wet, Moist)
Cr
Predominant Soil Series:
Precip. Past 24 Hrs.
inches
Pb
Date
Application Method*
Hg
Volatilization Rate**
Mo
*Application Method: S - Surface, IN - Injection, INC - Incorporation
**Volatilization Rate: Surface - 0.5, Injection/Incorporation - 1.0
*** Mineralization Rates: Compost -0.1, anaerobially digested -0.2, aerobically digested -0.3, raw sludge -0.4
****C.P.L.R.: Cumulative Pollutant Loading Rate
Field #:
Site #:
Crop 2 Name:
Mineralization Rate***
Ni
TKN
mg/kg
Se
Ammonia Nitrogen
mg/kg
Zn
Nitrate and Nitrite
mg/kg
P
PAN Applied ( lbs/acre)
Crop 1
Acres Utilized:
Acres Permitted:
Cation Exchange Capacity (non 503):
Crop 2 Max. PAN:
Crop 2
Name of Crop Type Receiving Residual Application
Crop 1
Lime Applied
Date
Crop 2
lbs/ac

ANNUAL LAND APPLICATION FIELD SUMMARY FORM
Supplemental Information
PLEASE MAKE A COPY OF THIS BLANK FORM TO BE COMPLETED AND SUBMITTED FOR EACH FIELD APPLIED ON
PLACE A "N/A" IN A BLANK OR BOX WHEN NOT APPLICABLE.
Date or Month
TOTALS:
“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.”
Facility Name:
Land Owner:
Operator:
Volume applied (enter one)
Cu. Yds
Signature of Land Applier
Crop 1 Name:
Gallons
% Solids
Volume Applied per Acre
(Dry Tons/Ac)
Residual Sources (NPDES #, WQ#, Fert., Animal Waste, etc)
WQ Permit #:
Annual Dry Tons Applied:
Crop 1 Max. PAN:
Soil Cond. (Dry, Wet, Moist)
Predominant Soil Series:
Precip. Past 24 Hrs.
inches
Date
Application Method*
Volatilization Rate**
*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
Field #:
Site #:
Crop 2 Name:
Mineralization Rate
TKN
mg/kg
Ammonia Nitrogen
mg/kg
Nitrate and Nitrite
mg/kg
PAN Applied ( lbs/acre)
Crop 1
Acres Utilized:
Acres Permitted:
Cation Exchange Capacity (non 503):
Crop 2 Max PAN:
Crop 2
Name of Crop Type Receiving Residual Application
Crop 1
Crop 2

ANNUAL PATHOGEN AND VECTOR ATTRACTION REDUCTION FORM (02T Rules)
Facility Name:
WWTP Name:
Monitoring Period: From
Pathogen Reduction (15A NCAC 02T .1106) - 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 (15A NCAC 02T .1107) - Please indicate alternative performed:
Alt.1 (VS reduction)
Alt. 5 (14-Day Aerobic)
Alt. 9 (Injection)
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*
*Preparer is defined in 40 CFR Part 503.9(r) and 15A NCAC 2T .1102 (26)
“I certify, under penalty of law, that the pathogen requirements in 15A NCAC 02T .1106 and the vector attraction reduction requirement in 15A NCAC 02T .1107 have been met.”
“I certify, under penalty of law, that the pathogen requirements in 15A NCAC 02T .1106 and the vector attraction reduction requirement in 15A NCAC 02T .1107 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.)
Alt. A (time/temp)
Alt.D (No Prior Test)
Heat Drying
Gamma Ray
Alt. (1) Fecal Density
Allowable Level in Sludge
2 x 10 to the 6th power per gram of total solids
1000 mpn per gram of total solid (dry weight)
3 MPN per 4 grams total solid (dry weight)
Air Drying
MPN
CFU
Alt. 2 (40-day bench)
Alt. 6 (Alk. Stabilization
Alt. 10 (Incorporation)
Pathogen Density
Minimum
Alt B (Alk Treatment)
Heat Treatment
Pasteurization
Alt. (2) Process to Significantly Reduce Pathogens
Geo. Mean
________
Date
To
Process to Further Reduce Pathogengs
Composting
Maximum
Alt. 3 (30-day bench)
Alt 7 (Drying - Stable)
No vector attraction reduction alternatives were performed
Land Applier Name and Title (if applicable)(type or print)
______________________________________
Signature of Land Applier (if applicable)
Units
Alt. C (Prior Testing)
Thermophilic
Number of Excee-dences
WQ Permit Number:
NPDES Number:
Aerobic Digestion
Frequency of Analysis
Alt. 4 (Spec. O2 uptake)
Alt. 8 (Drying - Unstable)
Sample Type
Analytical Tech-nique
_______
Date

ANNUAL PATHOGEN AND VECTOR ATTRACTION REDUCTION FORM (503 Rules)
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:
Alt.1 (VS reduction)
Alt. 5 (14-Day Aerobic)
Alt. 9 (Injection)
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*
*Preparer is defined in 40 CFR Part 503.9(r) and 15A NCAC 2T .1102 (26)
“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 per gram of total solids
1000 mpn per gram of total solid (dry weight)
3 MPN per 4 grams total solid (dry weight)
Air Drying
MPN
CFU
Alt. 2 (40-day bench)
Alt. 6 (Alk. Stabilization
Alt. 10 (Incorporation)
Pathogen Density
Minimum
Alternative 2
Alternative 5
Heat Treatment
Pasteurization
Alternative 2
Geo. Mean
________
Date
To
Composting
Maximum
Alt. 3 (30-day bench)
Alt 7 (Drying - Stable)
No vector attraction reduction alternatives were performed
Land Applier Name and Title (if applicable)(type or print)
______________________________________
Signature of Land Applier (if applicable)
Units
Alternative 3
Alternative 6
Thermophilic
Number of Excee-dences
WQ Permit Number:
NPDES Number:
Aerobic Digestion
Frequency of Analysis
Alt. 4 (Spec. O2 uptake)
Alt. 8 (Drying - Unstable)
Sample Type
Analytical Tech-nique
_______
Date