BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
Appendix D
Example Forms and Templates
Table D-1 — Critical Control Point Planning — BMP Procedures — Template
Table D-2 — Critical Control Point Planning — Level of Management System Development — Template
Table D-3 — Critical Control Point Planning — Level of Management System Development — Example
Table D-4 — Critical Control Point / Operational Control / Environmental Impact / Monitoring and
Measurement / Roles and Responsibilities — Example
Table D-5 — Applicable Legal Requirements and Permits — Template
Table D-6 — Biosolids Value Chain Roles and Responsibilities — Example
Table D-7 — Roles and Responsibilities by Biosolids Value Chain Category — Example
Table D-8 — Roles and Responsibilities by Goals and Objectives — Example
Table D-9 — Roles and Responsibilities by Departments and BMP Elements — Example
Table D-10 — Training Requirements by Job Title — Example
Table D-11 — BMP Training Log — Example
Table D-12 — Level 3 Documents and Forms — Document Map/Master List — Example
Table D-13 — Record of External Communication — Template
Table D-14 — Audit Checklist — Example
Table D-15 — Corrective Action Notice — Template
Table D-16 — Regulatory Requirements Checklist — Template
Table D-17 — Record of Emergency Incident/Response — Template
Table D-18 — Crop Harvesting Site Restriction Form — Example
Table D-19 — Field Summary Report — Example
Table D-20 — Landowner Consent Form — Example
Table D-21 — Field Compliance Summary — Example
Table D-22 — Notice to Land-Applier — Example
Table D-23 — Site Inspection Report — Example
The below templates are not required for use in an organization’s BMP Manual or other documentation.
However, they can be tools that organizations use to help organize their BMPs.
D-1
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-1 — Critical Control Point Planning — BMP Procedures — Template
Locations / Unit Processes
Biosolids
Value Chain
Potential
Critical
Control Points
Responsible
Party
Regulatory Requirements
Potential
Critical
Control Points
Responsible
Party
Events
Potential
Critical
Control Points
Responsible
Party
Activities
Potential
Critical
Control Points
Responsible
Party
Wastewater
Collection &
Pretreatment
Wastewater
Treatment &
Solids
Generation
Solids
Stabilization,
Conditioning &
Handling
Solids Storage
and
Transportation
Biosolids End
Use or
Disposal
D-2
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-2 — Critical Control Point Planning — Level of Management System Development — Template
Critical Control Point Category:
Critical Control Point
Completeness of
Documentation = X
No Systems
= 0 None
Limited Systems
= 2 Limited
Some Systems
= 4 Some
Basic Systems
= 6 Basic
Good Systems
= 8 Good
Full System
=10 Full
D-3
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-3 — Critical Control Point Planning — Level of Management System Development — Example
Biosolids Value Chain: Wastewater Collection and Pretreatment
Critical Control Point
Completeness of
Documentation = X
No Systems
= 0 None
Limited Systems
= 2 Limited
Some Systems
= 4 Some
Basic Systems
= 6 Basic
Good Systems
= 8 Good
Full System
=10 Full
SIU Industrial - Permits
Industrial User
Commercial User
SIU Inspections
SIU Monitoring
Zone Monitoring
SIU/Industrial Inspections
Enforcement
Technical Assistance
Spill Plan/Response
Other
D-4
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-4 — Critical Control Point / Operational Control / Environmental Impact / Monitoring and Measurement / Roles and
Responsibilities — Example
Biosolids Value Chain
Critical Control
Points
Operational Controls
Environmental Impacts
Monitoring/
Measurement/
Recordkeeping
Requirements
Roles and
Responsibilities
Wastewater Collection and
Pretreatment
Wastewater Treatment and
Solids Generation
Solids Stabilization,
Conditioning and Handling
Biosolids Storage and
Transportation
Biosolids End Use or Disposal
D-5
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-5 — Applicable Legal Requirements and Permits — Template
Biosolids Value
Chain
Applicable Legal
Requirements
Permit
Location
Owner
Wastewater
Collection and
Pretreatment
Wastewater
Treatment and
Solids Generation
Solids
Stabilization,
Conditioning and
Handling
Biosolids Storage
and Transportation
Biosolids End Use
or Disposal
D-6
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-6 — Biosolids Value Chain Roles and Responsibilities — Example
Position Description
Wastewater
Collection and
Pretreatment
Wastewater
Treatment and
Solids Generation
Solids Stabilization,
Conditioning and
Handling
Biosolids Storage
and Transportation
Biosolids Use or
Disposal
Utility General Manager
Director, Operations
Front-End
Superintendent
Back-End
Superintendent
Operator 1
Operator 2
Operator 3
Maintenance
Superintendent
Maintenance Tech1
Maintenance Tech 2
Regulatory Affairs
Laboratory
Engineering
Procurement
Human Resources
Contractor
D-7
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-7 — Roles and Responsibilities by Biosolids Value Chain Category — Example
Biosolids Value Chain: Wastewater Collection and Pretreatment
Personnel
Industrial
SIU Permits
Industrial SIU
Monitoring
Industrial
Permits
Industrial
Monitoring
Commercial
Permits
Inspection
Collection
Zone
Monitoring
Emergency
Response
Utility GM
Manager
Regulatory Affairs
Industrial Permit
Administrator
Commercial
Permit Admin
Field Tech 1
Field Tech 2
Field Inspector 1
Field Inspector 2
Lab Chemist
Lab Technician
Engineering
Contractor
D-8
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-8 — Roles and Responsibilities by Goals and Objectives — Example
Goals and
Objectives
Regulatory
Affairs
Operations
Front-End
Operations
Back-End
Engineering
Outside
Engineer
Laboratory
Contractor
Goal 1– Increase
Land Application
Objective 1A
Objective 1B
Objective 1C
Goal 2 – Reduce
Odor
Objective 2A
Objective 2B
Objective 2C
Goal 3 – Reduce
Lead and Copper
Objective 3A
Objective 3B
Objective 3C
D-9
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-9 — Roles and Responsibilities by Departments and BMP Elements — Example
EMS Elements
Senior
Management
Regulatory
AFfairs
Front-End
Operations
Back-End
Operations
Engineering
Procurement
Human
Resources
Contractor
1 – BMP Manual
2 – Biosolids Management
Policy
3 – Critical Control Points
4 – Legal and Other
Requirements
5 – Goals and Objectives
6 – Public Participation in
Planning
7 – Roles and
Responsibilities
8 – Training
9 – Communication
10 – Operational Control of
Critical Control Points
11 – Emergency
Preparedness and
Response
12 – Documentation,
Document Control, and
Recordkeeping
13 – Monitoring and
Measurement
14 – Nonconforances:
Corrective and
Preventive Action
15 – Biosolids Management
Program Report
16 – Internal BMP Audit
17 – Management Review
D-10
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-10 — Training Requirements by Job Title — Example
Job Title
Biosolids
Program
Overview
Biosolids
Legal and
Quality
Requirements
SOPs, Work
Instructions
Emergency
Response
Monitoring,
Measurement
Records
Storage and
Transportation
Certification
General Manager
Operations
Manager
WWTP Operators
Regulatory Affairs
Manager
Field Techs and
Inspectors
Biosolids Manager
Solids Operators
Truck Drivers
Biosolids
Contractor
Emergency
Contractor
D-11
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-11 — BMP Training Log — Example
Training Topic
Attendees
Frequency
Course Length
Course Method
Date Completed
Comments
BMP Awareness
Supervisor BMP Training
Biosolids Quality Overview
Transportation
Land Application
Emergency Response
Accident Investigation
Job-Specific Training (list)
Other
D-12
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-12 — Level 3 Documents and Forms — Document Map/Master List — Example
Biosolids Value Chain
Existing Form
Stand
Alone?
Location
Owner
Wastewater Collection and
Pretreatment
Wastewater Treatment
and Solids Generation
Solids Stabilization,
Conditioning and Handling
Biosolids Storage and
Transportation
Biosolids End Use or
Disposal
D-13
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-13 — Record of External Communication — Template
Description of Inquiry
Date Received
Date Responded
Type of Response
Name of Respondent
D-14
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-14 — Audit Checklist — Example
Auditee:
Document
Reference
Audit Number:
Requirement
Audit Standard:
Objective Evidence
Finding
Prepared By:
Date:
Prepared By:
Date:
D-15
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-15 — Corrective Action Notice — Template
Corrective Action Notice (CAN)
CAN Number:
Issue
Solution
Name:
Date:
Due Date:
Location:
Phone:
Requested by:
Issued to:
Problem Statement:
Most Likely Cause:
Implemented Solutions:
Results (confirming effectiveness):
Closed by:
Closing date:
D-16
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-16 — Regulatory Requirements Checklist — Template
Regulatory Requirement
(Citation)
Description

D-17
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-17 — Record of Emergency Incident/Response — Template
Record of Emergency Incident / Response
Date: _____________________________ Time: ________________________
Location: _________________________
Summary of Incident: __________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Response Actions:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Responsible Person (s): _____________________________
Company Phone No.: __________________________________
D-18
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-18 — Crop Harvesting Site Restriction Form — Example
D-19
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-19 — Field Summary Report — Example
D-20
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-20 — Landowner Consent Form — Example
D-21
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-21 — Field Compliance Summary — Example
D-22
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-22 — Notice to Land-Applier — Example
D-23
BIOSOLIDS MANAGEMENT PROGRAM GUIDANCE MANUAL
APPENDIX D — EXAMPLE FORMS AND TEMPLATES
Table D-23 — Site Inspection Report — Example
D-24