WQ0002638_ORC Designation_20020814

pen; 08/16/2002 03: 34 . 9196397131
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TOWN OF ANGIER
PAGE 01
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Water Popudon Control System Deslinatlon Form
WPCSOCC •
NCAC ;MING .0201
Gerierai Infotrittion:
Pennine. OwnerfOfficer Name:
Mailing Address: P. 0 Bee, •
City: tC4 r\S're K. . • State: 7S0
'Telephone idurnberli i/ )(39,Zr71 •
Signatize: 'new% •
•
Dotal:
• Facility iniOntstioni
Fit 'cilitYl•ZO,Lan 0 •Q. A•cc.
•Perth ruffiber: g s courty:
SUBMITA SEPARATE FORM:FOR EACH TYPE .00 SYSTEM !
Idatiaka*OLE141i1U OM (11— 4)
Wasteivater Plant
•PhyslealZhernical
Collection pyggin
9pemor Responsible Charge,
•
/06 r\ ,o; f4r.s4f.
0
Spray hri ation
Land Ap {cation
Suburb+ '
• 1
,' • . 1
• mulaiitt, e-mafLy' AzWlfri ocial Security il, : 2 2 iie - pie- 532a
Certificate Type to Grade: 40‘,43/ 47gArg941170/ "Crsraficate 0: ..e3 33c
Work Telephone: , (V? ) AjZgcA2L_ Signature: ecOrlifs7 /11.14 . A - • 1 • eit/t4
sal eeeeee tair'surem e .
Book -Up (Pinar in Resporsible•Ch4se: . .
P.rnit Norm 14r)( i ,..... Social.SeOurity
. ,
, .
/0 cv.,.‘—
On.
11/6
111A
Certifletterype and Grads:
Work Telephone: ( ) Ze..3.21.19AI
•
Mill pi Fax to: vinecsocc.'„'
• 161B Mail Series Center
Raleigh,, N.C., 27699.1611
Paz: 919/71.1338
c
rAfisfv 477 ..51a4w 7/y
C, ,6—ar3
Revised 1012440
PP 7 184-0 707
7r. • _I
C7.AT 7rx17 7T rrr-
TC I T ^Aft^ T /.7 . Sert 1

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 PERMIT #
OWNER SITE #
FIELD #
OPERATOR
TOTAL DRY TONS APPLIED (ANNUAL)
CATION EXCHANGE CAPACITY (non 503 regulated facilities only)
ACRES PERMITTED ACRES UTILIZED
DATE or
MONTH
Gallons /or Cubic Yards
(specify)
Dry Tons
per Acre
Residual Source
% Solids
(p.0 t of > ` :
use
Averages);;
Mineral-
zation Rate
Application
Method.ti�ese
See Code ;
.........
Ifrepvrtmg:by month:Ke
datly.records on site .<
Crop
Total
per Acre
Inches
Rainfall Past
74Flrc
Site Conditions
(Cry, Moist, Wet)
•
•
TOTALS:
Annual
Cumulative
Permit Limit (Ibs./acre/year) - 1st Crop / 2nd Crop
Permitted Cumulative Pollutant Loading Rate
Lime Application
DATE
LBS./AC.
* Code
S - Surface
I - Incorporation
IN - Injection
PAN
As
Cd
Cr
Cu
Pb
Hg
Mo
Ni
Se
Zn
X
(SIGNATURE OF LAND APPLIER) DATE
"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."
DEM FORM FSF(1/2002)