J-1604000-09 SAMPLE SLUDGE ANAYLSIS REPORT AND SLUDGE GENERATOR REPORT.pdf

1. Name/Address of Sewage Sludge Generator:

2. Sewage Sludge □ Raw, Unstabilized □Aerobically Digested

□Other (Describe):

□ □ Composted □ Lime Stabilized □Anaerobically Digested

MARYLAND DEPARTMENT OF THE ENVIRONMENT

1800 Washington Boulevard Suite 605 Baltimore, Maryland 21230-1719

410-537-3375 800-633-6101 (within Maryland) http://www.mde.state.md.us

Waste Management Administration Solid Waste Program Sewage Sludge Analysis Report

3. Sample Date: 4. Sample Type: □Grab □Composite

5. Laboratory Name:

6. Results of Analysis: (Attach a Copy of Laboratory Report)

Constituent Analyzed Value Units Detection

Limit Total Phosphorus TP mg/kg Total Potassium TK mg/kg Total Kjeldahl Nitrogen TKN % Ammonium Nitrogen NH4 % Nitrate Nitrogen NO3 mg/kg Cadmium Cd mg/kg Copper Cu mg/kg Nickel Ni mg/kg Lead Pb mg/kg Zinc Zn mg/kg Mercmy Hg mg/kg *Arsenic As mg/kg *Molybdenum Mo mg/kg *Selenium Se mg/kg PCBs PCB mg/kg **Calcium Carbonate Equivalent CaCO3 % Solids Content % pH

*Optional

Certification: As an authorized representative of the named sewage sludge generator, I certify that the information provided in this report is correct and complete to the best of my knowled2e.

Name: Title:

Signature:

Phone: ( )

Date:

MARYLAND DEPARTMENT OF THE ENVIRONMENT

1800 Washington Boulevard Suite 605 Baltimore, Maryland 21230-1719

410-537-3375 800-633-6101 (within Maryland) http://www.mde.state.md.us

Waste Management Administration Solid Waste Program

20XX Annual Sewage Sludge Generators Report (This Report Must Be Received By The Department By XX/XX/XXXX)

Billing name and address (if different than below):

County:

Facility:

Contact name and address:

Contact name and address (if incorrect):

Check sewage sludge stabilization process(es) used:

□ Unstabilized (raw) □ Aerobic digestion □ Anaerobic digestion □ Lime stabilization □ Composting

□ Other

Was any sewage sludge removed from your plant in the 20XX calendar year? D YES D NO (please explain below)

□ Storage □ Lagoon □ Other

In the following chart, enter the amount of sewage sludge removed from your plant in 20XX.

Figures should be expressed as both wet tons and dry tons.

Wet tons figures should be written in tons (2000 lbs/ton), at the percent solids the sewage sludge left the plant.

To convert gallons to wet tons use the following formula: gal x 8.34 lbs/gal x 1ton/2000 lbs.

(Or multiply the number of gallons by .00417) Dry tons figures are calculated by multiplying the total wet tons by the percent solids.

(i.e. for 18% solids, multiply the wet tons by .18 to calculate dry tons) If sewage sludge went to more than one county/site, please attach a separate sheet with that information.

If you are an out-of-State facility, please write only the tonnage that came to Maryland.

Category Amount in wet tons Amount in dry tons MD Site Specific Destination (County, Site name)

Applied to farm land in MD

Applied to marginal land in MD

Distributed / Marketed

Transported to another WWTP in MD

Transported out of MD

Taken to off-site storage in MD

Incinerated in MD

Landfilled in MD

Other

Total Removed From Plant

MAIL COMPLETED FORM TO:

Maryland Department of the Environment Waste Management Administration

Solid Waste Program 1800 Washington Boulevard, Suite 605

Baltimore, MD 21230-1719

Questions or for additional information, please call the Department at (410) 537-3375

Does your sewage sludge meet Maryland Class I metal limits? [See Code of Maryland Regulations (COMAR) 26.04.06.02(4)]

□ No □ Yes

Percent solids of sewage sludge: . %

Plant design capacity: MGD

Average daily flow to WWTP: MGD

Is there any sewage sludge currently stored at your plant? □ No □ Yes tons

Please list any sewage sludge contractor(s) and sub contractor(s) that handle the sewage sludge for you:

Check the method used to determine amount of sewage sludge reported:

o Trucks weighed before they left the plant o The number of trucks, of a known capacity, was counted o In-plant metering o Reports solely based on contractor billing statements or records o Reports partially based on contractor billing statements or records o Other (please describe or show calculations on a separate sheet of paper)

CERTIFICATION

As an authorized representative of the sewage sludge generator named on this form, I solemnly affirm under the penalties of perjury that the contents of this report are true to the best of my knowledge, information, and belief. Failure to submit this report is a violation of Maryland laws and regulations and could result in penalties to the generator. Information in this report is subject to audit by the Maryland

Department of the Environment.

Name (print) Title

Signature Date

Phone Number Fax Number Email Address