SEPTAGE MANAGEMENT PLAN WORKSHEET

GENERAL INFORMATION

1. __________________________________________________ 2. ____________________ 3. ________________________________

Exact Business or Corporate Name DEQ License No. Assumed Business Name
4. ________________________ 5. ____________________________________________________________________________________
Business Telephone Business Mailing Address
6. __________________________________________________________________________________________________________________
Street Address Business Is Conducted from, if Different from No. 5
7. Authorized Business Representative: ______________________ _______________ _______________ _______________________
First Name Middle Initial Last Name Title
8. Septage Sources and Approximate Volume (Gal/Yr) Pumped Annually:
A. Septic Tanks: _______________________ B. Holding Tanks: ______________________ C. Chemical Toilets: _________________
Gal/Yr Gal/Yr Gal/Yr
D. Vault Toilets: _______________________ E. Other Sources (Specify): _____________________________________________________
Gal/Yr Gal/Yr
9. Septage Disposal or Land Application Site Location:
A. SEWAGE TREATMENT PLANT WHERE MOST SEPTAGE DISPOSAL OCCURS:
• Sewage Treatment Plant: ______________________________ _________________________________ ___________________
Treatment Plant Name Location Telephone
a. Septage Sources and Volumes (Gal/Yr) Accepted by Treatment Plant:
i. Septic Tanks: _______________ ii. Holding Tanks: _______________ iii. Chemical Toilets: ______________________
Gal/Yr Gal/Yr Gal/Yr
iv. Vault Toilets: _______________ v. Other Sources (Specify): ____________________________________________________
Gal/Yr Gal/Yr
b. Location at Plant where Septage Received: ________________________________________________________________________
c. Provide a copy of a letter from the treatment plant operator which authorizes your business to dispose septage at the treatment
plant. The letter must indicate the type of septage the plant has agreed to receive from your business.
B. OTHER SEWAGE TREATMENT PLANTS WHERE SEPTAGE DISPOSAL OCCURS:
• Sewage Treatment Plant: ______________________________ _________________________________ ___________________
Treatment Plant Name Location Telephone
a. Septage Sources and Volumes (Gal/Yr) Accepted by Treatment Plant:
i. Septic Tanks: _______________ ii. Holding Tanks: _______________ iii. Chemical Toilets: ______________________
Gal/Yr Gal/Yr Gal/Yr
iv. Vault Toilets: _______________ v. Other Sources (Specify): ____________________________________________________
Gal/Yr Gal/Yr
b. Location at Plant where Septage Received: ________________________________________________________________________
c. Provide a copy of a letter from the treatment plant operator which authorizes your business to dispose septage at the treatment
plant. The letter must indicate the type of septage the plant has agreed to receive from your business.
• Sewage Treatment Plant: ______________________________ _________________________________ ___________________
Treatment Plant Name Location Telephone
a. Septage Sources and Volumes (Gal/Yr) Accepted by Treatment Plant:
i.Septic Tanks: _______________ ii. Holding Tanks: _______________ iii. Chemical Toilets: ______________________
Gal/Yr Gal/Yr Gal/Yr
iv. Vault Toilets: _______________ v. Other Sources (Specify): ____________________________________________________
Gal/Yr Gal/Yr
b. Location at Plant where Septage Received: ________________________________________________________________________
c. Provide a copy of a letter from the treatment plant operator which authorizes your business to dispose septage at the treatment
plant. The letter must indicate the type of septage the plant has agreed to receive from your business.
C. DEQ PERMITTED SOLID WASTE DISPOSAL FACILITY:
a. Disposal Facility Name: _______________________________________ b. Facility DEQ Permit No.: ____________________
c. Facility Type and Location: ______________________________________________________________________________________
d. Septage Sources and Volumes (Gal/Yr) Accepted by Disposal Facility:
i. Septic Tanks: _______________ ii. Holding Tanks: _______________ iii. Chemical Toilets: ______________________
Gal/Yr Gal/Yr Gal/Yr
iv. Vault Toilets: _______________ v. Other Sources (Specify): ____________________________________________________
Gal/Yr Gal/Yr
e. Location at Disposal Facility where Septage Received: ________________________________________________________________
f. Provide a copy of a letter from the treatment plant operator which authorizes your business to dispose septage at the treatment
plant. The letter must indicate the type of septage the plant has agreed to receive from your business

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 D. DEQ AUTHORIZED BENEFICIAL USE SITE (PRIMARY SITE):
a. Location of Primary Site Used
for Septage Application: ______________ _____________ _______________ _______________ ___________________
1/4 Section Section Township Range County
b. Site Owner: ___________________________________ _____________________________________________________________
Name Address
c. Site Size: ________________ d. Crop Grown: _____________________________
Acres
e. Method of Septage Application: __________________________________________________________________________________
f. Septage Application Rate: ________________________________
Gal/Acre/Yr
g. Septage Sources and Volumes (Gal/Yr) Applied to Beneficial Use Site:
i. Septic Tanks: _______________ ii. Holding Tanks: _______________ iii. Chemical Toilets: ______________________
Gal/Yr Gal/Yr Gal/Yr
iv. Vault Toilets: _______________ v. Other Sources (Specify): ____________________________________________________
Gal/Yr Gal/Yr
h. Provide a map of the Land application site showing areas DEQ approved for septage application.
i. Provide a copy of a letter from DEQ which authorizes your business to dispose of septage at the site and identifies conditions for
septage application.
j. Provide a copy of a form or page from the ledger your business uses to track: (i) volume septage applied; (ii) application date; (iii)
locations of the field where septage was applied; (iv) person who applied septage; etc.
k. In the site owned by your DEQ licensed Sewage Disposal Service Business? … Yes … No
(If you answered “No”, provide a copy of the agreement your business has with the site owner which authorized you to apply septage
to the site.)
l. Provide a description of any septage treatment (e.g., Line Stabilization) which occurs before or following land application.
E. DEQ AUTHORIZED BENEFICIAL USE SITE (BACKUP SITE):
a. Location of Backup Site Used:__________ _____________ _______________ _______________ ___________________
1/4 Section Section Township Range County
b. Site Owner: ___________________________________ _____________________________________________________________
Name Address
c. Site Size: ________________ d. Crop Grown: _____________________________
Acres
e. Method of Septage Application: __________________________________________________________________________________
f. Septage Application Rate: ________________________________
Gal/Acre/Yr
g. Septage Sources and Volumes (Gal/Yr) Applied to Beneficial Use Site:
i. Septic Tanks: _______________ ii. Holding Tanks: _______________ iii. Chemical Toilets: ______________________
Gal/Yr Gal/Yr Gal/Yr
iv. Vault Toilets: _______________ v. Other Sources (Specify): ____________________________________________________
Gal/Yr Gal/Yr
h. Provide a map of the Land application site showing areas DEQ approved for septage application.
i. Provide a copy of a letter from DEQ which authorizes your business to dispose of septage at the site and identifies conditions for
septage application.
j. Provide a copy of a form or page from the ledger your business uses to track: (i) volume septage applied; (ii) application date; (iii)
locations of the field where septage was applied; (iv) person who applied septage; etc.
k. In the site owned by your DEQ licensed Sewage Disposal Service Business? … Yes … No
(If you answered “No”, provide a copy of the agreement your business has with the site owner which authorized you to apply septage
to the site.)
l. Provide a description of any septage treatment (e.g., Line Stabilization) which occurs before or following land application.

10. Pumper Vehicle Description(s):

A. How many septage pumping vehicles (includes pumper trucks and tank trailers) does your business operate? _______________________
B. Provide a copy of the most recent Department of Environmental Quality “Sewage Pumping Equipment Description/Vehicle
Inspection” form (DEQ-WQ-License/WH823) completed for each pumper truck you operate. Be sure the form has been signed by a
representative from the Department of Environmental Quality or its authorized County Agent.
11. Provide a description of any interim storage/transfer facilities used for holding septage pending disposal or application elsewhere:
A. Type Storage Facility: ______________________________________ B. Volume Facility: ` _________________________________
C. Sources(s) Septage Stored:
a. Septic Tanks: … Yes … No b. Holding Tanks: … Yes … No c. Chemical Toilets: … Yes … No
d. Vault Toilets: … Yes … No e. Other: … Yes … No __________________________________________________________
Specify
D. Is the facility authorized through a DEQ permit? … Yes … No. If “Yes”, list DEQ Permit Number. _______________________
Permit Number

DEQ-08-WQ-042