LAND APPLICATION SITE INFORMATION - OPERATION AND ...



|SEPTIC TANK, CESSPOOL, AND PRIVY CLEANER |

|LAND APPLICATION - OPERATION AND MAINTENANCE PLAN |

|Company Name:       |DEQ License Number:       |

|Location of Disposal Records:       |

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|SITE INFORMATION |

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|Land Application Site Name:       |

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|Site Address:       |City:       |

|Directions to Site: |

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|Legal Description of Site: |Section:    |Township:    |Range:    |County:       |

|(to nearest ¼ section)       /4 | | | | |

|Number of acres for land application: |Type of Crop: |Crop Nitrogen Requirement: (pounds per acre per year --- lbs |

| | |N/acre/yr) |

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|WASTE INFORMATION |

|Check all that apply at this site: |Estimated total gallons during license year: |

| |Septage |      |

| |Portable toilet/Vault toilet type waste |      |

| |Grease Trap Waste |      |

| |Sump Pumpings (specify type below) |      |

| |‪ Automatic Car Wash Bay Sump |      |

| |‪ Attended Car Wash Bay Sump |      |

| |‪ Unattended Car Wash Bay Sump |      |

| |‪ Other Sump ‪ (specify type) ______________ |      |

| |Graywater |      |

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|SITE OPERATION AND MAINTENANCE |

|LIST MEASURES TO CONTROL ACCESS TO THE SITE: |

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|LIST VECTOR ATTRACTION AND PATHOGEN REDUCTION METHODS USED: |

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|LIST ANIMAL GRAZING AND CROP HARVESTING RESTRICTIONS FOR THE SITE: |

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|LIST EQUIPMENT AVAILABLE TO MANAGE EACH TYPE OF WASTE: |

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