LAND APPLICATION OF RESIDUAL WASTE ANNUAL OPERATION REPORT. Instructions

Transcription

1 2520>FM>LWM0408 ev. 8/97 25 PA Code DEPATMENT OF ENVIONMENTAL POTECTION BUEAU OF LAND ECYCLING AND WASTE MANAGEMENT LAND APPLICATION OF ESIDUAL WASTE ANNUAL OPEATION EPOT Instructions 1. This report is due on or beore March!1 each year covering the period January!1 to December!31 o the preceding year. 2. Send one (1) copy o the report and the check or the administrative ee made payable to the Commonwealth o Pennsylvania to the attention o the Solid Waste Manager in the egional Oice listed below. 3. Send one (1) copy o the report to: Bureau o Land ecycling and Waste Management Division o Waste Minimization and Planning P.O. Box 8472 Harrisburg, PA 17105> The report orms may be reproduced without modiication o content. IDENTIFY ALL ATTACHMENTS BY PEMIT NUMBE AND DATE PEPAED EGIONAL OFFICES (and counties served) DEP Southeast egion Lee Park, Suite North Lane Conshohocken, PA 19428>2233 Phone: 610>832>6212 Bucks > Chester > Delaware > Montgomery > Philadelphia DEP Northcentral egion 208 W. Third Street, Suite 101 Williamsport, PA 17701>6448 Phone: 717>327>3653 Bradord > Cameron > Centre > Clearield > Clinton > Columbia > Lycoming > Montour > Northumberland > Potter > Snyder > Sullivan > Tioga > Union DEP Northeast egion 2 Public Square Wilkes>Barre, PA 18711>0790 Phone: 717>826>2516 Carbon > Lackawanna > Lehigh > Luzerne > Monroe > Northampton > Pike > Schuylkill > Susquehanna > Wayne > Wyoming DEP Southcentral egion One Ararat Boulevard Harrisburg, PA 17110>9714 Phone: 717>657>4588 Adams > Bedord > Berks > Blair > Cumberland > Dauphin > Franklin > Fulton > Huntingdon > Juniata > Lancaster > Lebanon > Milin > Perry > York DEP Southwest egion 400 Waterront Drive Pittsburgh, PA 15222>4745 Phone: 412>442>4000 Allegheny > Armstrong > Beaver > Cambria > Fayette > Greene > Indiana > Somerset > Washington > Westmoreland DEP Northwest egion 230 Chestnut Street Meadville, PA 16335>3481 Phone: 814>724>8526 Butler > Clarion > Craword > Elk > Erie > Forest > Jeerson > Lawrence > McKean > Mercer > Venango > Warren 1 o 5

2 2520>FM>LWM0408 ev. 8/97 25 PA Code DEPATMENT OF ENVIONMENTAL POTECTION BUEAU OF LAND ECYCLING AND WASTE MANAGEMENT LAND APPLICATION OF ESIDUAL WASTE ANNUAL OPEATION EPOT YEA SITE INFOMATION (Please type or print) Name o Permittee Phone ( ) Name Street County Municipality City State Zip Tax I.D. or S.S.# A. Type o Facility: (Check One) " Agricultural Utilization " Land Disposal " Land eclamation B. Topographic Map Attach a topographic map o the same scale and contour interval as the map submitted with the application, showing the ield boundaries where residual waste has been applied, and the volume applied to each ield or other designated application area. C. List permitted sites where residual waste was not applied during the report year. Attach additional sheets with the same headings i needed. Permittee Pemit No. Site Name County Township 2 o 5

3 2520>FM>LWM0408 ev. 8/97 25 PA Code DEPATMENT OF ENVIONMENTAL POTECTION BUEAU OF LAND ECYCLING AND WASTE MANAGEMENT LAND APPLICATION OF ESIDUAL WASTE ANNUAL OPEATION EPOT GENEATO INFOMATION INSTUCTIONS: Enter the Name, Mailing Address, County (PA County) and State o each Generator under the column titled Generator Inormation. Enter the 3 digit Code number (rom the Waste Code Appendix) or each waste type applied. Enter the total Weight to the nearest 1/10 ton, o each waste type applied in the spaces in the proper column. Enter the State abbreviation rom Table 2, and the PA County Code rom Table 1. Enter the generator inormation only once or each generator. Leave the Generator Inormation Section blank or additional waste codes rom the same generator. Generator Inormation (Type or Print) % Solids Waste Code (From Appendix) Total Weight or Volume in Tons or Gallons TOTAL FO THIS SHEET 3 o 5

4 2520>FM>LWM0408 ev. 8/97 25 PA Code ß DEPATMENT OF ENVIONMENTAL POTECTION BUEAU OF LAND ECYCLING AND WASTE MANAGEMENT LAND APPLICATION OF ESIDUAL WASTE ANNUAL OPEATION EPOT For the report year (January 1 to December 31) (enter year) D. CETIFICATION OF ANALYSIS Certiication that the operator has received the analysis or certiication required by ß (relating to chemical analysis o waste) or each type o waste received at the acility, and that the residual waste that is received at the acility meets the condition in the acilityπs permit. " All required analyses were received during the year. E. SOILS ANALYSIS For agricultural utilization and surace land disposal acilities which have received residual waste in the calendar year, please submit a chemical analysis o soil or each ield at the acility or ph, phosphorous, cadmium, zinc, copper, lead, nickel, chromium, mercury and any other constituents contained in the waste that may be leached into the environment as determined under ß unless otherwise speciied by the Department in the permit. F. ANNUAL GOUNDWATE MONITOING EVALUATION Include results o annual groundwater monitoring i required by the Department. G. PEMIT AND OPEATION STATUS 1. Change o Ownership > Identiication o Interests > Compliance Inormation. " NO. I NO, complete a copy o Form!C1 Compliance History Certiication (2500>PM>LWM0195) and attach it to this report. " YES. I YES, complete a copy o Form!C, Compliance History (2540>FM>LWM0058) and attach it to this report. 2. ight o Entry > Lease Agreement > Land Ownership. " NO. " YES. I YES, submit a revised copy o Form!E, Contractual Consent o Landowner (2540>PM>LWM0353). Changes involving land ownership may require the submittal o Part!B2 and B3 o Form!C concerning surace or subsurace land ownership. H. PEMIT ADMINISTATION FEE Please submit a check payable to the Commonwealth o Pennsylvania. Attach the check to one o the copies being sent to the egional Oice. " > Agricultural Utilization o esidual Waste. " 1, > Land eclamation with esidual Waste. " 1, > Surace Land Disposal o esidual Waste. I. FINANCIAL ASSUANCE 1. Attach a written update o the total bond liability or the acility in accordance with Section! > bond amount determination and > bond amoung adjustments. I additional bond is determined to be necessary, it shall be submitted to the Department within 90 days ater the annual report is due. " Additional bond is not required. eport is attached. " Additional bond will be submitted. eport is attached. 4 o 5

5 2520>FM>LWM0408 ev. 8/97 25 PA Code ß DEPATMENT OF ENVIONMENTAL POTECTION BUEAU OF LAND ECYCLING AND WASTE MANAGEMENT LAND APPLICATION OF ESIDUAL WASTE ANNUAL OPEATION EPOT For the report year (January 1 to December 31) (enter year) 2. Attach a current Certiicate o INsurance as speciied in Section! >> (a).! IDENTIFY ALL ATTACHMENTS BY PEMIT NUMBE AND DATE PEPAED Oicer Certiication This is to certiy that I have personally examined this report and am amiliar with the inormation submitted in it and all attached documents. I am aware o the Department o Environmental Protection requirements or this report and this acility. To the best o my knowledge, inormation and belie, the inormation submitted is true, accurate, and complete. I am aware that there are signiicant penalties or submitting alse inormation. Name o Oicer Signature Title (Please Print) Date Telephone 5 o 5