Instructions 140123

State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
INSTRUCTIONS FOR RESIDUALS APPLICATION ANNUAL REPORTING FORMS:

The Division of Water Resources will not accept an annual report package unless all the instructions are followed. Failure to submit all of the required information is a violation of
permit conditions.
For more information, links to forms requested in this application, or for an electronic version of this form, visit the Non-Discharge Permitting Unit (NDPU) web site at: http://deq.nc.gov/about/divi
sions/water-resources/water-resources-permits/wastewater-branch/non-discharge-permitting-unit/reporting-forms
General Instructions (All Application Packages):
The instructions for the following forms are presented:
Cover Letter A cover letter is required as part of all Residuals Application Annual Reports
FORM ACF Annual Land Application Certification Form
FORM DMSDF Class A Annual Distribution And Marketing/ Surface Disposal Certification And Summary Form
FORM DMSDF (Supp) Class A Annual Distribution And Marketing/ Surface Disposal Certification And Summary Form – Supplementary Information
FORM RSSF Annual Residual Sampling Form (Standard parameters)
FORM RSSF – B Annual Residual Sampling Form (Blank Form)
FORM MFLSF Annual Metals Field Loading Summary Form
FORM FSF Annual Land Application Field Summary Form
FORM FSF(Supp) Annual Land Application Field Summary Form – Supplementary Information
LAB SHEETS THIS IS NOT A FORM, but is included to show the order in which items shall be submitted.
FORM PVRF 2T Annual Pathogen and Vector Attraction Reduction Form for NCAC 2T Rules
FORM PVRF 503 Annual Pathogen and Vector Attraction Reduction Form for CFR 503 Rules
FIELD SOILS TEST THIS IS NOT A FORM, but is included to show the order in which items shall be submitted.
Submit the annual report in the order shown above. The cover letter should always be first, followed by the standard forms. Not all of the above forms are required for every land application
program. See instruction below for clarification on which forms are required. All supplemental information and lab sheets should be clearly organized and placed after the standard
forms. See instructions below for information on ordering lab sheets.
The Forms described herein are the only approved forms that may be used for submittal of the Annual Land Application Report. The Division must approve other forms before they are submitted
as part of the Annual Report, or the annual report may be returned as incomplete. Contact the Non-Discharge Permitting Unit for more information on adaptations of existing forms.
These forms can be filled out electronically or by hand. If filling out electronically, please note that some of the information is automatically calculated and entered into the spreadsheet.
Please fill out the forms in the order that they are presented.
All forms are protected to help assure that changes are not inadvertently made to the form. If you wish to manually enter data into protected cells the page may be unprotected using
the password “2T”, or call the Non-Discharge Permitting Unit for Assistance.
The forms must be signed appropriately in accordance with 15A NCAC 2T .0106(b). An alternate person may be designated as the signing official, provided that a delegation letter is provided
from a person who meets the referenced criteria.
Include the WQ permit number and facility name on all forms. The facility name must match the facility name on the WQ Permit.
If necessary for clarity, include attachments to the forms. Such attachments will be considered part of the Annual Report and should be numbered to correspond to the section to which
they refer.
All sampling results (lab sheets) required by permit and gathered over the previous year must be submitted.
Assure that lab sheets clearly identify which field or residual source they are associated with.
Please note that adjustments may have to be made to your printers properties when printing

If you have any questions regarding the changes in the FSF Form, the newly created MFLSF Form, or how to utilize these forms for your program please contact the Non-Discharge Permitting
Unit at [phone], or visit the NDPU website for Staff contact information https://deq.nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/non-discharge-permitting.
Cover Letter (Required for all Residuals Programs submitting an Annual Report):
Submit a cover letter, which lists all items and attachments included in the annual report as well as a brief description of the previous years operation.
The Cover Letter should include contact information for the Permittee as well as the preparer of the forms in the event that additional information is required for completion of the
annual report.
The Cover letter should include a narrative description of any event of non-compliance that occurred the previous year, as required in FORM ACF, DMSDF, and PVRF.
The Cover letter should include a written explanation of any other irregular event as required as part of any of the Annual Report Forms.
FORM ACF (Required for Programs applying Class B Residuals to permitted fields):
The Annual Land Application Certification Form (FORM ACF) provides information on the total amounts of residual applied, how the permitted acreage was utilized, and certifies that the
permitted program was compliant with all permit condition over the previous calendar year.
If the program was not compliant for the entire year, a written description of the following items shall be included in the Cover Letter:
Date and time span of non-compliance
Explanation of action (or lack of action) that caused non-compliance.
Corrective action taken
Action taken by DWR to date (if any).
The Permittee (or a properly delegated authority), as well as the Land Applier if different from the Permittee or Preparer, must sign this form.
FORM DMSDF (Required for Programs producing Class A Residuals for distribution or sale, and for programs utilizing surface disposal):
The Class A Annual Distribution And Marketing/ Surface Disposal Certification And Summary Form (FORM DMSDF) provides information on the residual sources and recipients of the processed
residuals, and certifies that the permitted program was compliant with all permit condition over the previous calendar year.
This spreadsheet contains formulas in the light-green shaded cells that will automatically calculate the annual dry tons of amendments (bulking agents), “residuals in” for treatment,
“product out” of treatment, and volume of product received by recipients if a permit number is entered into the spreadsheet.
Surface disposal facilities are required to complete only part of FORM DMSDF. See specific instructions on the form.
If the program was not compliant for the entire year, a written description of the following items shall be included in the Cover Letter:
Date and time span of non-compliance
Explanation of action (or lack of action) that caused non-compliance.
Corrective action taken
Action taken by DWR to date (if any).
If multiple sources or recipients are utilized in a given month, the Permittee may use FORM DMSF (supp) to list all of the sources and recipients used for each month. If the supplemental
information form is used, indicate the number of additional forms submitted at the bottom of the table on this form.
The Permittee (or a properly delegated authority), as well as the Preparer, if different from the Permittee, must sign this form.
FORM DMSDF (Supp) (Optional form for additional information required in FORM DMSF):
The Class A Annual Distribution And Marketing/ Surface Disposal Certification And Summary Form Supplemental Information: (FORM DMSDF (Supp)) provides additional space for listing residuals
sources and recipients on a monthly basis for programs required to complete FORM DMSDF.
This Form is not a substitute for FORM DMSDF.
Surface disposal facilities are required to complete only part of FORM DMSDF (Supp). See specific instructions on the form.
If multiple FORM DMSDF (Supp) are used, indicate the number of additional forms submitted at the bottom of the table.
This spreadsheet contains formulas in the light-green shaded cells that will automatically fill in the contact information from FORM DMSDF, and calculate the annual dry tons of amendments
(bulking agents), “residuals in” for treatment, “product out” of treatment, and volume of product received by recipients if a permit number is entered into the spreadsheet.

FORM RSSF (Required for all residuals programs):
The Annual Residuals Sampling Summary Form (FORM RSSF) provides yearly sampling results of standard pollutants of concern associated with most residuals permits for each permitted residuals
generating source.
A separate Form must be submitted for each permitted residuals generating source.
All sampling results (lab sheets) gathered over the previous year must be submitted, and included in the LAB SHEETS section of the annual report (see below).
TCLP results do not need to be entered into either Form RSSF or Form RSSF – B.
If parameters not included on the form are included in the Facility’s permit, or have been sampled by the Permittee, FORM RSSF – B must be completed and submitted with these sampling
results.
A list of all laboratories used to analyze the samples must be provided.
The Preparer (or a properly delegated authority), must sign this form.
FORM RSSF – B (Required for residual generating sources with sampling results not covered by FORM RSSF:
The Annual Residuals Sampling Summary Form - B (FORM RSSF - B) provides yearly sampling results of additional pollutants of concern not included in FORM RSSF as described above.
A separate form must be submitted for each permitted residuals generating source.
TCLP results do not need to be reported on this form
All sampling results (lab sheets) gathered over the previous year must be submitted, and included in the LAB SHEETS section of the annual report (see below).
A list of all laboratories used to analyze the samples must be provided.
The Preparer (or a properly delegated authority), must sign this form.
Please attach all RSSF forms for a particular Source together.
FORM MFLSF (Optional form that must be submitted only if used by programs applying Class B residuals to permitted fields):
The Annual Metals Field Loading Summary Form (FORM MFLSF) provides analytical results for residuals applied to a specific field, as well as the annual metals loading to that field.
This spreadsheet contains automatic formulas in the light-green shaded cells that will calculate the annual dry tons applied and the annual metals loading once the permit number, residual
data, and the total dry tons per acre per event are entered into the spreadsheet.
This Spreadsheet is linked to FORM FSF. Be sure to verify the results on this spreadsheet, and that the data is correctly being transferred to FORM FSF.
The person responsible for land application to this field must sign this form.
FORM FSF (Required for programs applying Class B residuals to permitted fields):
The Annual Land Application Field Summary Form (FORM FSF) provides information on the amounts of Plant Available Nitrogen (PAN), and annual and cumulative metals applied to the field.
FORM FSF must be completed and submitted for every permitted field receiving residuals. If a permitted field does not receive residuals for an entire calendar year please note this
in the narrative of the cover letter.
This spreadsheet contains formulas in the light-green shaded cells that will automatically calculate the following information once the permit number, gallons or cubic yards applied
per event, percent solids, forms of nitrogen, and all other information is entered into the spreadsheet.
Volume Applied per acre (dry tons/acre)
Annual dry tons applied
PAN Applied (lbs/acre): once the name of the crop type is entered for either Crop 1 or Crop 2 column (only one should be entered) the corresponding PAN Applied column will be calculated.
Total Volume of residuals applied
Total PAN applied to each crop type.
Current Cumulative Loading of metals
The dry tons of residuals applied per acre is calculated assuming that there are 206.96 gallons of residuals per cubic yard. If site-specific data exists indicating a different volume
conversion is required contact the Division for approval and instructions for updating the spreadsheet.
When entering the “Volume Applied” to the field the Preparer must enter either the volume in cubic yards or in gallons in the corresponding column. If both values are entered the spreadsheet
will use the cubic yard value to calculate the dry tons per acre applied.
This Spreadsheet is linked to FORM MFLSF. Verify the results on this spreadsheet, and that the Annual Lbs/acre for each metals is correctly being transferred from FORM MFLSF.
This Spreadsheet is linked to FORM FSF (SUP). Verify the results on this spreadsheet, and that the Annual Lbs/acre of PAN for each crop type is correctly being transferred from FORM
FSF (SUP).
All field soils tests gathered over the previous year must be submitted and included in the FIELD SOILS TEST section of the annual report (see below)

The person responsible for land application to this field must sign this form.
FORM FSF (SUP) (Optional Form for additional information required in FORM FSF):
The Annual Land Application Field Summary Form Supplementary Information (FORM FSF) provides additional space to track land application events and Nitrogen PAN loading for a field.

FORM SFS (SUP) must be completed and submitted when FORM FSF does not provide adequate space for all land application events. This form can also be used to track application of fertilizer
and animal wastes.
This spreadsheet contains formulas in the light-green shaded cells that will automatically fill in information previously entered into FORM FSF, and calculate the following information
once the permit number, gallons applied per event, percent solids, nitrogen speciation, and all other information is entered into the spreadsheet.
Volume Applied per acre (gallons/acre)
PAN Applied (lbs/acre): once a crop type is entered for either crop 1 or crop 2 (only one should be entered) the PAN Applied to that crop will be calculated.
Total Volume of residuals applied.
Total PAN applied to each crop type.
When entering the “Volume Applied” to the field the Preparer may enter either the volume in cubic yards or gallons. It is recommended that cubic yards be reported if the residuals are
applied as a dry cake, and that gallons are reported if the residuals are applied as a liquid. Regardless of which volume is reported, it is essential that the %solids reported correspond
to the type of volume reported. If both gallons and cubic yards are reported report the % solids for the dry cake (cubic yard value), as the spreadsheet will use the cubic yard value
to calculate the dry tons per acre applied.
This Spreadsheet is linked to FORM FSF. Verify the results on this spreadsheet, and that the Annual Lbs/acre of PAN for each crop type is correctly transferred to FORM FSF.
All field soils tests gathered over the previous year must be submitted and included in the FIELD SOILS TEST section of the annual report (see below)
The person responsible for land application to this field must sign this form.
LAB SHEETS (Required for all Programs performing sampling as part of FORM RSSF, and RSSF - B):
All sampling results (lab sheets) gathered over the previous year must be submitted.
Assure that lab sheets clearly identify which residual source they are associated with.
Organize all lab sheets associated with FORM RSSF by residual source in the same order that FORMS RSSF are organized
Sampling results for TCLP sampling must be included.
FORM PVRF 02T and 503 (Required for most Residuals Programs submitting an Annual Report, refer to individual permit conditions to verify if pathogen and vector attraction reduction requirements
are appropriate.):
The Annual Pathogen and Vector Attraction Reduction Form (FORM PVRF) provides certifications that appropriate actions were taken to properly reduce pathogens and vector attraction potential.

Pathogen reduction and vector attraction reduction alternative and options listed in this form as part of 15A NCAC 02T .1106 and .1107, match the alternatives and options listed in 40
CFR 503.32 and .33 respectively. The Preparer should verify which regulations are identified in their permit and certify the corresponding form.
The preparer of the form must check one of the two boxes supplied indicating whether the requirements have been met or not. If the requirements have not been met, the Permittee must
include an explanation of the following in the narrative of the submitted Cover Letter
Date and time span of non-compliance
Description of alternative or option attempted and explanation of action (or lack of action) that caused non-compliance.
Corrective action taken.
Action taken by DWR to date (if any).
The copy of the analytical results or supporting documentation (e.g. time/temperature records) must be submitted verifying that the pathogen and vector attraction reduction requirements
have been met by the indicated method.
The person responsible for land application to this field and the preparer (if different from the Applier) must sign this form.

FIELD SOIL TESTS (Required for Programs Applying Class B Residuals to Permitted Fields ):
All field soils test sampling results gathered over the previous year must be submitted.
Make sure that soils test sheets clearly identify which field(s) they are associated with, and that the field numbers on the test sheets are consistent with the field names used in the
permit.
Organize all field soils sheets associated with FORM FSF by field name in the same order that FORMS FSF are organized.

THREE COPIES OF THE COMPLETED ANNUAL REPORT FORMS, INCLUDING ALL SUPPORTING INFORMATION AND MATERIALS, SHALL BE SENT TO THE FOLLOWING ADDRESS:

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER RESOURCES
WATER QUALITY PERMIT SECTION
NON-DISCHARGE PERMITTING UNIT
By U.S. Postal Service: By Courier/Special Delivery:
INFORMATION PROCESSING UNIT INFORMATION PROCESSING UNIT
6TH FLOOR 6th FLOOR
DIVISION OF WATER RESOURCES DIVISION OF WATER RESOURCES
1617 MAIL SERVICE CENTER 512 N. SALISBURY STREET
RALEIGH, NORTH CAROLINA 27699-1617 RALEIGH, NORTH CAROLINA 27699