ATTACHMENT F - RESIDUALS ANNUAL SUMMARY AND RESIDUALS MONITORING REPORT
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ATTACHMENT F
RESIDUALS ANNUAL SUMMARY
(DEP FORM 62-640.210(2)(b))
AND
RESIDUALS MONITORING
REPORT
(DEP FORM 62-640.210(2)(d))
28
Florida DepartmentofEnvironmental Protection
Twin Towers Office Bldg, 2600 Blair Stone Road, Tallahassee, Florida 32399.2400
Residuals Annual Summary
Part I - Facility Information
FACILITY NAME:
FACILITY ID:
MAILING ADDRESS:
MONITORING PERIOD -- From: JAN 1,
To: DEC 31,
Total Quantity of Residuals Applied DurinQ ReportinQ Period:
Total Number of Residuals Land Application Sites Used Durino Reportino Period:
residuals land application sites used)
dry tons
{Parts II and III should address all
7
9
'All units are in a dry weight basis except for total solids and pH. All sampling and analysis shall be conducted pursuant to Title 40 Code of Federal Regulations, Section 503.8, and the
POTW Sludge Sampling and Analysis Guidance Document.
N/A = not applicable
Pathogen Reduction Class (Rule 62-640.600(1), FAC.): 0 A
EPA Vector Attraction Reduction Option (Rule 62-640.600(2), FAC.):
01 02 03
D6 D7 D8
DB
04
D9
05
010
Certification
I certify under penalty of law that I have personally examined and am familiar with the information submitted herein; and based on my inquiry of those individuals immediately
responsible for obtaining the information, I believe the submitted information is true, accurate and complete. I am aware that there are significant penalties for submitting false
information, includino the oossibilitv of fine and imorisonment.
NAME/TITLE OF PRINCIPAL EXECUTIVE OFFICER OR AUTHORIZED AGENT (Type or Print) TELEPHONE NO.
SIGNATURE OF PRINCIPAL EXECUTIVE OFFICER OR AUTHORIZED AGENT DATE (YY/MMIDD)
DEP Form 62.640,210(2)(b), F,A.C., effectivel2101/97
Page 1
Site Name (as identified in Agricultural Use Plan):
Part II. Total Application of Residuals or Septage, Nutrients, and Trace Elements for Application Zones Used Only By This Facility (attach a separate sheet for "other solids," if applicable):
H H L.S.D., INC.
#Err ANNUAL SUMMARY
212012008
Site Address (~ shown in Agricultural Use Plan):
#Error
(Enter all nutrient and trace element quantities in Ibs/acre)
Ng,te: Annual c~mulative loadings are products of weighted averages based on each facility's acreage alotment within zone, and are not additive.
#Error
Page 2
Part III. Total Residuals or Septage, Nutrients, and Trace Elements Applied to Application Zones Used by Multiple Facilities (attach separate page for "other solids," if applicable):
Facility (as shown in Agricultural Use Plan):
Site Name (as identified in Agricultural Use Plan):
Site Address (as shown in Agricultural Use Plan): /tError
H H L.S.D., INC.
IErr ANNUAL SUMMARY
212012008
(Enter nutrients and trace elements in Ibs/acre.)
",!ote: Annual cumulative loadings are products of weighted averages based on each facility's acreage alotment within zone, and are not additive.
#Error
2007 BIOSOLIDS REPORT
Facility:
Facility ID:
01/10/08
Land Applicaton Summary
Total Amount of Residuals Generated: Q Metric Tons 0.0 Dry Tons
Total Area of Land Application: Q Hectares 0.0 Acres
Land Applicator: H & H Liquid Sludge Disposal, Inc.
P.O. Box 390
Branford, FL 32008
1. Site Owner: Ag Use Site Owner Loadina Rates: Q Metric Tons 0.00 tons 0.0 dtJac
Site Location: Site Address Q Hectares 0.00 acres
City, State
Coordinates
2. Site Owner: Ag Use Site Owner Loadina Rates: Q Metric Tons 0.00 tons 0.0 dtJac
Site Location: Site Address Q Hectares 0.00 acres
City, State
Coordinates
3. Site Owner: Ag Use Site Owner Loadina Rates: Q Metric Tons 0.00 tons 0.0 dtJac
Site Location: Site Address Q Hectares 0.00 acres
City, State
Coordinates
4. Site Owner: Ag Use Site Owner Loadina Rates: Q Metric Tons 0.00 tons 0.0 dtlac
Site Location: Site Address Q Hectares 0.00 acres
City, State
Coordinates
H & H L.S.D., Inc. . 100 E. Linton Blvd. STE 208B . Delroy Bch. FL 33483
Main Office: Po. Box 390 . Branford. FL 32008
Florida Department of Environmental Protection
Twin Towers Office Bldg., 2600 Blair Slone Road, Tallahassee, Florida 32399-2400
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Residuals Monitoring Report
FACILITY NAME:
FACILITY 10:
MAILING ADDRESS:
MONITORING PERIOD -- From:
To:
Quantity of residuals treated by this facility during this reporting period (dry tons):
Residuals class produced by this facility: DAA DAD B
Required frequency of analysis for this facility:
Date of sample collection (attach a copy of the analvticallaboratorv reports):
Laboratorv name FL Lab certificate no.
-All units are in a dry weight basis except for total solids and pH. All sampling and analysis shall be conducted pursuant to Title 40 Code of Federal Regulations, Section 503.8, and the
POTW Sludge Sampling and Analysis Guidance Document.
N1A = not applicable
Description of Pathogen Reduction Method Used
Plant Staffinq: 1 st Operator
2nd Operator
3rd Operator
4th Operator
Class
Class
Class
Class
Name
Name
Name
Name
Certificate No.
Certificate No.
Certificate No.
Certificate No.
Certification
I certify under penalty of law that I have personally examined and am familiar with the information submitted herein; and based on my inquiry of those individuals for obtaining the
information, I believe the submitted information is true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the
Dossibilitv of fine and imDrisonment.
NAMElTITLE OF PRINCIPAL EXECUTIVE OFFICER OR AUTHORIZED AGENT (Type or Print) TELEPHONE NO.
SIGNATURE OF PRINCIPAL EXECUTIVE OFFICER OR AUTHORIZED AGENT DATE (VYIMM/DD)
DEP Form 62-640.210(2)(d), effective 12/01197
Northwest Dlalrlct
160 Govemmental Center
PBtlSacal., Florida 32501-5794
904-444.8300
North...t OislJlcl
7825 Baymeadawe, Suil. 8200
Jackson~II.. Florid. 32256-7577
904-4411-4300
Pagel
Cenlnll0i8llk:t
3319 Mogul.. Blvd, SUite 2:l2
OriBndo, FIoIIdo 321103-3787
407-894-7555
Southweet District
3804 Coconut Palm Drive
Tampa, Florida 33619.8218
813.744-8100
SoulhDi81ricl
2295 Victoria Ave., Suile 364
Fort Myers, Florid. 33901
813-332-8975
Southel!lalOistrict
400 N. Oo"g.... Ave.
Weal P~m Beach, ROOda 33llO1
407-881-8800
Hauling Records Summary
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DEP Form 62'640.210(2)(d), enective 12/01/97
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INSTRUCTIONS FOR RESIDUALS MONITORING REPORT
This form shall be completed for each permitted residuals management or septage management facility in accordance with Chapter 62-640, Florida Administrative Code (F AC.). The
permittee shall submit the report by no later than the 28th day of the month that follows the month in which the monitoring was performed. The permittee shall submit the report to the
appropriate Department District Office. All information shall be typed or printed in ink.
Facility Name/Address: Enter the facility name as shown on the facility wastewater permit Complete the mailing address.
Facility 10: This is the identification number of the facility as it appears on the facility wastewater permit.
Monitoring Period: This is the period that the data on this report represents.
Quantity of residuals treated by this facility during this reporting period: Enter the total quantity of residuals treated by the facility during the reporting period in dry tons
(1 ton = 2ooOlb).
Residuals class produced by this facility: Select AA, A, or B as appropriate.
Required frequency of analysis for this facility: Enter the frequency of analysis specified in the permit for this facility (i.e., "every 30 days', etc.).
Date of sample collection: Enter the date the sample was actually collected. Attach a copy of the laboratory analysis report. The laboratory must be certified in Florida. All sampling
and analysis shall be conducted pursuant to TiUe 40 Code of Federal Regulations, Section 503.8.
Laboratory Name: Enter the name of the laboratory that performed the analysis.
FL Lab certificate no.: Enter the'IEi6.oratOtVs ofnciar Flofrtili''CIttrftb8te number. ."' . 'f';" f 'j...-,
Table of analysis parameters and concentrations: Enter the concentrations from the laboratory analysis for the listed parameters in the indicated units. All units are in a dry weight
basis except for total solids and pH. The density of at least one of the two pathogen types must be entered for Class AA and Class A residuals. Fecal coliform density must be reported
for Class B residuals that utilize EPA's "Alternative 1" method for Class B pathogen reduction.
Plant staffing: Enter each operator's class of certification, their certificate number, and name as it appears on their certificate.
Certification: This report must be signed in accordance with Chapter 62-640, F.A.C. Type or print the name and tide of the signing official. Include the telephone number where the
official may be reached. Enter the date the report is signed.
Hauling Records Summary: Enter the applicable information to Indicate the sources and quantities of residuals received on a monthly basis.
DEP Form 62-640.210(2)(d), effeclive 12101/97
Page 3
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