Attachment C - Sample Form 7264 - Page 1.pdf
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- Solicitation number
- 3000025032
- Issued by
- Acadia Parish, Baton Rouge City, Louisiana
About this file
This document is a Louisiana Department of Environmental Quality (DEQ) Form 7264, a Sewage Sludge & Biosolids Use or Disposal Reporting Form designed for sanitary wastewater treatment facilities to report annual sewage sludge removal activities. The form is to be submitted to the Office of Environmental Services, Water Permits Division in Baton Rouge, Louisiana, and requires facilities to document the amount of sewage sludge generated (in gallons and tons per year) and provide detailed information about pumpers, haulers, or transporters who remove sewage sludge from their facility.
The form includes a mandatory certification statement where the reporting individual must affirm under penalty of law that the submitted information is true, accurate, and complete, with acknowledgment of potential significant penalties for submitting false information. The reporting is required on an annual basis, covering the previous calendar year's activities (January 1st - December 31st), and necessitates specific details such as the facility name, agency interest number, contact person, permit number, and precise quantities of sewage sludge removed by each transporter.
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Text version
Attachment C: Sample Form 7264 Title: Water Treatment Services -LOH
SEWAGE SLUDGE & BIOSOLIDS USE OR DISPOSAL REPORTING FORM
DEC! . I FOR
i.o�aa,u, SEWAGE SLUDGE PUMPED OUT OR REMOVED FROM A SANITARY WASTEWATER TREATMENT
WORKS AND SOLD, GIVEN AWAY, AND/OR HAULED OFF-SITE FOR A FEE OR OTHER
CONSIDERATION
(Non:: A separate form must be filled out if your Use or Disposal Option is: (1) Disposers of Sewage Sludge (2) Land Application (3) Receivers of Sewage Sludge From Outside Sources or (4) Incineration)
NOTE: The reporting requirement is on an Annual Basis. The form must be filled out with information to completely cover the previous year's activities (January I '1 - December 31") and submitted to:
Name of Facility:
A2ency Interest#:
TEMPO t\ctivity #:
Louisiana Department of Environmental Quality Office of Environmental Services
Water Permits Division Post Office Box 4313
Baton Rouge, Louisiana 70821-4313
I Contact Person:
I Permit#:
(1) Date of Report: _______________ _
I I
(2) Reporting Period: From: ___________ To: _____________ _
(3) Amount of Sewage Sludge generated by the facility: Gallons/Year __ _ Tons/Year
(4) Information Regarding the Pumper/Hauler/Transporter that removed Sewage Sludge from your Facility (If necessary, add additional sheets.):
Name of Pumper/Hauler/Transporter or Address Contact Phone Gallons/Yr Tons/Yr
Facility That Removed the Number Removed Removed Sewal!e Sludee
(5) Certification Statement:
"l certify u�der penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gathered and evaluated the information submitted. Based on my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of a fine and imprisonment for knowing violations."
Signature: _______________ _ Date signed: ____________ _
Form 7264 rO I
08/23/11
File details come from the government source that posted it. Updated .