ADEQ Biosolids Applicator Annual Report Form

This form is a supplemental ADEQ web form for biosolids land applicators’ annual reports that needs to be completed in addition to the online reporting required via EPA's NeT Biosolids Reporting portal. Please complete the following information and click SUBMIT.

General Information

Reporting Period:

AZPDES Permit # (if applicable):

Land Application Registration LTF#(s) (List all that apply):

Company Name (Applicator):

Facility Type:

Contact Person:

Name:

Title

Ph#:

Email:

Field/Farm Information:

Farm
Site/Farm Name: Field ID: Amount Applied (DMT): Preparer: Class Pathogen Treatment Method: Vector Attraction Reduction Method: Loading Rate (DMT/Acre): Nitrogen Concentration (Organic + Ammonium) (mg/kg): Crop Grown: Agronomic Rate of Crop Grown (lbs/acre): As (mg/kg) Cd (mg/kg) Cr (mg/kg): Cu (mg/kg): Pb (mg/kg): Hg (mg/kg): Mo (mg/kg): Ni (mg/kg): Se (mg/kg): Zn (mg/kg):

Source Information:

Source Information
Sources of Material for Biosolids: Categorize Facility: NAICs Code(s): Not sure what NAICS code to use? \| View Code List > Types of Waste Expected:

Address of Source:

Address of Source
Address Line 1: Address Line 2: City: State: Zip: