Free 50397.pdf - Indiana

DIRECTIONS FOR THE USE OF THE QUARTERLY LAND APPLICATION REPORTS
COPY AND USE THIS REPORT FORM AND THIS REPORT FORM ONLY. Use as many report form sheets as needed. USE A SEPARATE SET OF REPORT FORM SHEETS FOR EACH AND EVERY DIFFERENT SITE THAT HAS BEEN APPROVED.
(1) (2) (3) (4) (5) (6) Record the required information Daily for each load that is land applied. What was the volume applied in gallons per load. What type of load was it, domestic septage only, grease only or a mixture of both. What Method of application was used per load, surface, surface with incorporation or injection. How much Square footage or Actual Acreage was used per load. What was the Crop Nitrogen Requirement per load [(50# for grass, pasture, set aside or otherwise idle) (100# for soybeans, wheat or hay)(200# for corn)].

(7)

A pH of twelve (12) or higher must be held prior to land application. The pH test must be done twice, once at the start of the time period and once at the end of the time period (Thirty [30] minutes for domestic septage & Two [2] hours for mixed loads) Lime must be used to treat domestic septage and mixed loads to achieve pathogen reduction and vector attraction reduction. Who was the Vehicle operator, the name of the person who applied the load. The Permittee Must Sign each report form to verify that the pathogen requirements and vector reduction requirements have been met.

(8)
(9)

Reports must be submitted to the "Office of Land Quality, Solid Waste Permits Section, PO Box 6015, Indianapolis IN 46206-6015, attention Mr. Jim McCurdy, Septage Program", no later than one (1) week after the below dates. Failure to submit the reports in a timely matter could result in enforcement action being taken against your business and revocation of your current approval and denial of any future approval request.

REMEMBER QUARTERLY REPORTS MUST BE SIGNED AND SUBMITTED EVEN IF THERE WAS NO LAND APPLICATION ACTIVITY DURING THE QUARTER. First Quarter Ends Second Quarter Ends Third Quarter Ends Fourth Quarter Ends
State Form 50397 (R/12-02)

March 31 June 30 September 30 December 31

State Form # 50397 (R12-02) Business Name: Business Permit Number: Site ID Number & County: Page of Land Application Report for the Quarter of

Date of Application

Volume Applied in Gallons

Type of Load Septic/Mixed/Greasee

Method of Application

Actual Used Square Footage/Acreage

Crop Nitrogen Requirements

pH & Duration (test 1 & test 2)

Vehicle Operator

I certify under penalty of law, that the pathogen requirements and the vector attraction reduction requirements in 327 IAC 7.1-8-9 have been met. This determination has been made under my direction and supervision in accordance with the system designed to ensure that qualified personnel properly gather and evaluate the information used to determine that the pathogen requirements and vector attraction reduction requirements have been met. I am aware that there are significant penalties for false certification including the possibility of fine and imprisonment.
State Form 50397 (R/12-02)

Permittee's Signature: Date: Total Gallons of Wastewater Applied this Quarter: