Residual Solids Annual Report

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Water Treatment Plant

Residual Solids Annual Report

Wastewater Permit Program

Doc Type: Annual Report

Reporting Period: September 1,      , through August 31,      

This form must be completed and submitted annually by January 31st for the previous cropping year. Attach to this form a copy of all laboratory analysis results. In addition, be sure to send any requested information to City, Township, and County officials.

Return completed forms to:

Water Quality Submittals Center

Minnesota Pollution Control Agency

520 Lafayette Road North

St. Paul, Minnesota 55155-4194

Part 1 – General Information

Permittee information:

Permit name:


Permittee number:


Permittee mailing address:








Facility contact:


Telephone number:


Information on person preparing this form:



Telephone number:


Mailing address:








Type IV certification number:


Expiration date (mm/dd/yyyy):


 Check here if no water treatment plant residual solids were disposed during this cropping year.
(Sign in Part 3 and mail to the address above.)

Part 2 – Solids Disposal (List all by-products and the quantities disposed during this cropping year.

By-product disposed:  Lime Water filter backwash solids

Method of disposal:  Construction fill  Landfilled  Land application  Wastewater Treatment Plant (WWTP)

Total quantity disposed:       dry tons

If landfilled, radium-226 concentration:       pCi/g Ra-226 (dry mass)

Submit the following, if applicable:

  1. Location of disposal.

  2. Analytical results.

  3. Cumulative amount of arsenic and radium-226 pollutant applied to the application site.

Part 3 – Certification

I certify that I am familiar with the information contained in this report and that to the best of my knowledge and belief the information is true, accurate and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment.

Principal executive officer/authorized agent: Type IV certified operator:

Print name:


Print name:











Signature: • 651-296-6300 • 800-657-3864 • TTY 651-282-5332 or 800-657-3864 • Available in alternative formats

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