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Type of Visit: fa',,C,,,,,,,,,,,,,,,......pppoppp������mpliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: 4xoutine 0 Complaint A2rFollow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: 1f 3 Arrival Time: 2Ud Departure Time: 'lUUip County
Farm Name: �.1 I�47E,e� CS e_ /e, 1 Owner Email:
Owner Name: „�yyk eya/ ty Phone:
Mailing Address:
Physical Address:
Facility Contact: doy 6 Title:
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Phone:
Integrator:
Certification Number:
Certification Number:
Longitude:
Region:
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Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWR)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWR)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
❑ Yes ❑ No �' A ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
[—]Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No [_]NA ❑ NE
❑ Yes ❑ No �] NA ❑ NE
❑ Yes [:]No _Q-NA ❑ NE
Page 1 of 3
511212020 Continued

Facility Number: Date of Inspection: U t
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes ❑ No E3'NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structure 1 Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier:
Spillway?: _
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
❑ No _f7T`NA
❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a
❑ Yes
❑ No AErNA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health
or environmental
threat, notify DWR
7. Do any of the structures need maintenance or improvement?
❑ Yes
❑ No �❑'NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
❑ No aNA
❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require
❑ Yes
❑ No _,f7—NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
❑ No [�J-NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below.
❑ Yes
❑ No _'NA
❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge
into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s):
14. Do the receiving crops differ from those d rgnated in the MP?
❑ Yes
❑ No .FrNA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
❑ No C;'NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
❑ No .En'&A
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
❑ No .INA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
❑ No ,INA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
the appropriate box.
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements
❑ Yes e'No ❑ NA ❑ NE
❑ Yes .E�J'No ❑ NA ❑ NE
❑ Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes .allo
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes 01Vo
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes ..TNo
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3
511212020 Continued

Facility Number: jDate of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes ❑ No ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes []No ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge? ❑ Yes ❑ No ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
❑ Yes
❑ No
❑ NA
❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
❑ No
J "NA
❑ NE
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
❑ No
[ A
❑ NE
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
❑ Yes
❑ No
❑-NA
❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Yes
❑ No
aNA
❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
❑ No
aNA
❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
❑ No
,e A
❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
❑ No
,❑-NA
❑ NE
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Cuj Phone: 91y - g35-- 91-FS-
Date:
511212020