820266_INSPECTIONS_20171231

NORTH CAROLINA
Department of Environmental Qual

1 m 5
5 t_1
Type of Visit: p CC liance Inspection O Operation Review O Structure Evaluation O Technical Assistance I
Reason for Visit: Routine O Complaint O Follow-up Q Referral Q Emergency O Other O Denied Access
Date of Visit: Arrival Time: S i 5 Departure Time: 1 County:
Farm Name: �� `� 1 C (_ �e.,-7 Owner Email:
Owner Name:. ��-�% Phone:
Mailing Address:
Physical Address:
Facility Contact: CCtu—( Z�.w _ Title: Phone:
Onsite Representative: It Integrator: �4]
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Certification Number:
Certification Number:
Longitude:
Region: ! 4
Design
Current
Design
Current
Design
Garreat
Swine
Capacity
Pop.
Wet Poaltry
:.
Capacity
Pop.
Cattle
Capacity
Pop.
u¢.
mui
�,f ruaiu�aiau
�
Wean to Finish
La er
DairyCow
Wean to Feeder
Non -Layer
Dairy Calf
Feeder to Finish
Dairy Heifer
Farrow to Wean
f
` "Design
Cnrreat
. '
Dry Cow
Farrow to Feeder
Non-Dai
Farrow to Finish
La ers
Beef Stocker
Gilts
Non -La ers
Beef Feeder
Boars
Pullets
Beef Brood Cow
W
Turk e s
OtIle
Turkey Pouets
Other
Other
Discha es 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 EA�-1 off'❑ NA ❑ NE
❑ Yes [] No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes []"No
❑ Yes Ej No
[]"IV A ❑ NE
Q-1gA ❑ N E
❑ NA
❑ N E
❑NA
❑NE
❑ NA
❑ NE
Page I of 3 21412015 Continued

Facility Number: - Date of Inspection: 3 Fet
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? es ['No ❑ NA ❑ NE
a. if yes, is waste level into the structural freeboard? ❑ Yes &< ❑DNA ❑ NE
Structure l Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): 7 —
5. Are there any immediate threats to the integrity of any of the structures observed?
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a
waste management or closure plan?
❑ Yes E�<o ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
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 [2-No ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes D"'o ❑ NA ❑ 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 [;INo ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes CTNo [] NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes [r] No ❑ NA ❑ NE
❑ Excessive Ponding 0 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): `lrk(-:OfA .S C% C—)
13. Soil Type(s): f ,�� VC,
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes ❑-No ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes [�No ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes Q No ❑ NA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
[ o
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
[-1 o
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
[—]Yes
❑
❑ NA
❑ NE
20. Does the facility fail to have al[ components of the CAWMP readily available? If yes, check
[—]Yes
[3'<o
❑ NA
❑ NE
the appropriate box.
❑WUP ❑Checklists ❑Design ❑ Maps ❑ Lease Agreements ❑Other:
21 _ Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes I:aKo
❑ 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 [
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes U �No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑NA ❑NE
Page 2 of 3 21412015 Continued

Facility Number: g _ 16 jDate of Inspection:
/
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
B5-<o
❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check
❑ Yes
[ o
❑ 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 provide documentation of an actively certified operator in charge?
❑ Yes
[;3,<o
❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
❑ Yes
❑-f4o
❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
[2-No
[ ] 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
dNo
❑ NA
❑ NE
f 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? I f yes, check the appropriate box below.
❑ Yes
E21'1�o
❑ NA
❑ NE
❑ Application Field ❑ Lagoon./Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWIVIP?
❑ Yes
E; No
❑ NA
[] NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
o
❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
YNo
❑ NA
❑ NE
as necessary) „
�, � ��y-•t,� 10 � '� � —� [ � .S'�Q� ,•er �t..�'-�r� r (1�a2 v I � i � J . 5 (�— .J �
L)
Reviewer/Inspector Name:
ReviewerAnspector Signatw
Page 3 of 3
Phone -A 0
Date:
21412015

(Type of Visit: (!`Compliance Inspection O Operation Review p Structure Evaluation O Technical Assistance I
Reason for Visit: 'Routine O Complaint O Follow-up O Referral O Emergency p Other O Denied Access
Date of Visit: Arrival Time: Departure Time: County: r` Region:"v
Farm Name: fa't Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: Title:
Onsite Representative: t
Certified Operator: �t
Back-up Operator:
Phone:
Integrator: 19
Certification Number: t oo`ij
Certification Number:
Location of Farm: Latitude: Longitude:
Design Current
Design CurrentDesign Furrent
Swine Capacity Fop. „
W,et Poultry
Capacity . Pop, Cattle ..- Capacity
P-op.
Wean to Finish
La er
Dairy Cow
Wean to Feeder
Non -La er
I
K
Dairy Calf
Feeder to Finish
. pr
- $`
`$
Dairy Heifer
Farrow to Wean
`-
i Desi nCiirre
g
art:
Dry Cow
Farrow to Feeder
0-7171PITUlt .
Capa ci
1Poxx
Non -Dairy
Farrow to Finish
Layers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turkeys
==
Other
Turkey Poults
' V
Other
Other.:
Discharees 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)?
❑ Yes to ❑ NA ❑ NE
❑ Yes ❑ No E&NA ❑ NE
❑ Yes ❑ No [3NA ❑ NE
d. Does the discharge bypass the waste management system? (If yes, notify DWR) ❑ Yes o No eNA ❑ NE
2. Is there evidence of a past discharge from any part of the operation? ❑ Yes [� No ❑ NA ❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters ❑ Yes No ❑ NA ❑ NE
of the State other than from a discharge?
Page I of 3 21412015 Continued

I' ficili Number: - Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate'?
0 Yes
No
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No
[✓ "NA
❑ NE
Structure I Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
pp
Observed Freeboard (in): h
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
�o
0 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
❑ NA
❑ 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
]Vo
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
❑'No
❑ NA
❑ 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
[ o
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
[:]-No
❑ NA
❑ NE
maintenance or improvement?
11. is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes El"'No DNA ❑ 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): k.4 p
13. Soil Type(s): Cdn, O!fV- _.
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes 62'Ao ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes Z_No ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes [rNo ❑ NA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
[RrNo
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
[n No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
[]�go
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes. check
❑ Yes
[3No
❑ NA
❑ NE
the appropriate box.
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes [a -No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1 " Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes [1 No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes �no
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 21412015 Continued

Facility Number: - Date of Inspection:JJT
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes OoNo
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes E�Ko
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 fast survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge? ❑ Yes EErNo
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes 1 =1 o
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
®No
❑ 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
LJ�Xo
❑ NA ❑ 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
El"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
ED No
❑ NA ❑ NE
❑ Application Field ❑ Lagoon/Storage pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
�o
❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
❑' To
❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
[r3'No
❑ NA ❑ NE
Comments (refer to question ft Explain any YES answers and/or any additional recommendations or any other comments.
Use drawings of facility to better explain situations (use additional pages as necessary).
t 17 4c IC-18v
q(0 n- 6�SC
Reviewer/Inspector Name: 1 id- Phone: t �-7 3-n }
Reviewer/Inspector Signature: Lt A VM Date:`
Page 3 of 3 2/4/2015

Type of Visit: C'lCompliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: GKkoutine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Othhe'r(� 0 Denied Access
Date of Visit: Arrival Time: Departure Time: ounty: , C�� Region:r��
Farm Name: 04a�Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: e&,, 1 Title: Phone:
Onsite Representative: l Integrator: W
Certified Operator: ! l Certification Number: t 91_qjL
Back-up Operator: Certification Number:
Location of Farm:
Latitude: Longitude:
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation? ❑ Yes [e�"No ❑ NA ❑ NE
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 DWQ)
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 DWQ)
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 [ J�A ❑ NE
[::]Yes [:]No �A ❑ NE
❑ Yes
❑ No
[�t'NA
❑ NE
[::]Yes
[ o
❑ NA
❑ NE
[—]Yes
E'� No
❑ NA
❑ NE
Page l of 3 21412011 Continued

Facility Number: - Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes F;Hfoo ' ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? [:]Yes [—]No E!11TA ❑ 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 [-Vo ❑ 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 dNo ❑ NA ❑ 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 C!rNo ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes dNo ❑ NA ❑ 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 ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need [:]Yes No ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes o ❑ 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): &4� -5—C [D
13. Soil Type(s): h/ jq /V p
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes ❑i'No ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes Z�No ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes F--INo ❑ NA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
Reauired Records & Documents
❑ Yes UXo ❑ NA ❑ NE
❑ Yes [jjIsio ❑ NA ❑ NE
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
[�
❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
[>No
❑ NA ❑ NE
the appropriate box.
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements
❑Other:
21. Does record keeping need improvement? if yes, check the appropriate box below.
❑ Yes
"No
❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis
❑ Waste Transfers
[] Weather Code
❑ Rainfall [] Stocking [] Crop Yield ❑ 120 Minute Inspections ❑ Monthly and I " Rainfall Inspections
❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge?
❑ Yes
E!rNo
❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes [�o ❑ NA ❑ NE
Page 2 of 3 21412014 Continued

Facilitf-Number: - Date of Insoection:
24. Did the facility fail to calibrate waste application equipment as required by the permit?
` 4
❑ Yes
o
❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check
❑ Yes
�To
❑ 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
CR<o
❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
❑ Yes
dNo
❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
[:]Yes
[�10
❑ 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
❑ NA
❑ 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
E?fNo
❑ 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
❑ NA
❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
[a Yes
�/
I /i o
❑ NA
❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
LJ No
❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
�(No
❑ NA
❑ NE
Comments (refer to question #): Explain any YES answers and/or anyadditional recommendations or any other comments
Use drawings of facility to better explain situations (use additional pages as necessary):
16 (g" 5 Cf.jr '0 4�
41
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: q,33
Date: (0
-06
214,1244

Type of Visit: ®'Compliance Inspection O Operation Review p Structure Evaluation O Technical Assistance I
Reason for Visit: E ooutine 0 Complaint O Follow-up Q Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: Departure Time: County: RegionF-
Farm Name: (" - 1 ley Owner Email.
Owner Name: 1` 1 lew Phone:
Mailing Address:
Physical Address:
r
Facility Contact: ^ ` .e Title:
Onsite Representative: ! i Integrator:
Certified Operator: 1
Back-up Operator:
Location of Farm:
Latitude:
Phone:
Certification Number: Lr3 I
Certification Number:
Longitude:
Design
Curren t
Design
'Current
= �F*, Design Gurreot
Swine
Capacity
Pop Wet Poultry
Capacity
PopCattle���
Ca aci Po
Wean to Finish
Layer
Dairy Cow
Wean to Feeder
Non -La er
I
Dairy Calf
Feeder to Finish
r
Da' Heifer
Farrow to Wean
T :.> - - -
Design
Curredts
Dry Cow
Farrow to Feeder
.e ;Pout
Ca aci
P,o
Non -Dairy
Farrow to Finish
H Layers
=
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
_ M .: �'r. Turkeys
Other -
Other
Turkey Poults
Other
Discharees and Stream ImDaCtS
1. Is any discharge observed from any part of the operation? ❑ Yes Ed>6 ❑ NA ❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made? ❑ Yes [—]No NA [] NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ) ❑ Yes ❑ No Q NA [] NE
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 DWQ) ❑ Yes ❑ No E�"NA ❑ NE
2. Is there evidence of a past discharge from any part of the operation? ❑ Yes Zf No ❑ NA ❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters ❑ Yes E?rNo ❑ NA ❑ NE
of the State other than from a discharge?
Page 1 of 3 21412011 Continued

Facility Number: - Date of Ins ection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes,
U-Na'O NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
[:]No U1�A
❑ 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
ag o ❑ NA
❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
No
6. Are there structures on -site which are not properly addressed and/or managed through a
❑ Yes
R3 ❑ NA
❑ 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 DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes [2No ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? [:]Yes dNo ❑ NA ❑ 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 dNo ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes dNo ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes &o ❑ 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): Q e,r-" .5-(. o
13. Soil Type(s): NC✓- i
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes �No ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement'? ❑ Yes ["No ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable [:]Yes [ZNo ❑ NA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
[:]Yes [ 'No ❑ NA ❑ NE
❑ Yes [2/No ❑ NA ❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes [allo ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes [Z No ❑ NA ❑ NE
the appropriate box.
❑WUP ❑Checklists ❑Design ❑ Maps ❑ Lease Agreements []Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes [ZNo
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis O Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and i" Rainfall Inspections
(
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes 1TNo
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment`? ❑ Yes [/f No
❑NA ❑NE
❑ Weather Code
❑ Sludge Survey
❑NA ❑NE
❑ NA ONE
Page 2 of 3 21412011 Continued

Facility umber: JDate of Ins ection-
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes [21Vo ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes Eg o ❑ 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
CTo
❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
❑ Yes
[eNo
❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
CJNo
❑ 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
2(No
❑ NA ❑ 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 VNo ❑ 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
ZNo
❑ NA
❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
CyNo
❑ NA
❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
E o
❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
WNo
❑ NA
❑ NE
C-k
194gp'su,l'll
Reviewerllnspector Name:
Q-Rs—[S o- q-i P q'v 3 87t
" 0 D'tA
Reviewer/Inspector Signature:
Page 3 of 3
Phone:
Date: S
2/420 4

Onsite Representative: S ack�
Certified Operator: �..�
Back-up Operator:
Location of Farm:
Type of Visit: t� omptiance Inspection V Operation Review O Structure Evaluation (> Technical Assistance I
Reason for Visit: GH, outine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time:F—jW--,67Tj Departure Time: County:Region
Or
Farm Name: / t ; Lie y r a lr_ Owner Email: `
J r
Owner Name: C,:�, Phone:
Mailing Address:
Physical Address:
Facility Contact: Ce' 1+. 'R , IY y Title: Pew n Ys—
Integrator:
Certification Number:
Latitude:
Phone:
Certification Number:
Longitude:
= Design Current Design Current
Swine Ca�ac Po VVe# Ponl �-
P, t}' � p• .. try . Capact�ty ,Pap.
_Cattle-
Design Current
Capacity Pop.
o Finish
La er
Dai Cow
o Feeder
Non -La er
Dai Calf
to Finish
`'
Design
' "' .
Current
Dai Heifer
to Wean
E
Cow
to Feeder
D , P:ou1 .aaci
La ers
Po
Non -Dairy
to Finish
Beef Stocker
Non -La ers
Beef Feeder
Pullets
Beef Brood Cow
Turkeys
INI
Other _
Turkey Poults
Other
I
Other
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 DWQ)
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 DWQ)
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 RNo ❑ NA 0 NE
❑ Yes [:]No
❑ Yes [:]No
❑ Yes ❑ No
❑ Yes [3 No
❑ Yes kl
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Page 1 of 3 21412011 Continued

Facility Number: jDate of Inspection:
—1 NI
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
® No
❑ 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): I`1
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
®,No
❑ 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
❑ NA
❑ 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 DWQ
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
Z No
❑ NA
❑ 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
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
® No
❑ 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): el
13. Soil Type(s): %era D(f
14. Do the receiving crops from those designated in the CAWMP?
❑ Yes
01 No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
RYes
❑ No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
nNo
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
[ZNo
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
Callo
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
0No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
Callo
❑ NA
❑ NE
the appropriate box.
[] WUP ❑ Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes I& No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rainfall Inspections ❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? [:]Yes E[No ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? [:]Yes 2LNo ❑ NA ❑ NE
Page 2 of 3 21412011 Continued

Facility Number: - Date of Ins ection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes C& No ❑ NA ❑ NE
• 25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes 0 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:
2& Did the facility fail to provide documentation of an actively certified operator in charge? ❑ Yes [R 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
ENo
❑ 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
[R No
❑ NA
❑ 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
❑ NA
❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes ® No ❑ NA ❑ NE
33. Did the Reviewerllnspector fail to discuss review/inspection with an on -site representative? ❑ Yes ® No ❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency? ❑ Yes Eg-No ❑ NA ❑ NE
Comments (refer to question if): Explain any YES answers and/or any additional recommendations or any other comments.
Use drawings of facility to better explain situations (use additional pages as necessary).
/ S =121aul
/j�fira`� o� f S��d 's�'Z�v r
Reviewer/Inspector Name:
Reviewed]nspector Signature:
Phone:
Date: 71 13
21412011
Page 3 of 3

Type of Visit: Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance I
Reason for Visit: Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: r r/ Arrival Time: Departure Time:. �� County:.�.�-
Farm Name: Carl /R . )zy 1=12/M, Owner Email:
Owner Name: C,5"1-1 14. (�t j , y Phone:
Mailing Address:
Physical Address:
Facility Contact: Oar , Title: fh Yr— Phone:
Onsite Representative: �S'6c,c� Integrator:�/I y
Certified Operator: Certification Number:
Back-up Operator: Certification Number:
Location of Farm: Latitude: Longitude:
Region: FR a
Design Current,
Des"
Currentr
Desigu C*urrent
Swine
s
Ca aci ty 1Po �� Wet.Poul
Ca achy
Rop Cattle . Capacity Pop.
Wean to Finish
�
La
Dairy Cow
Wean to Feeder
er
Non -La er
Dairy Calf
Feeder to Finish"IDairy
Heifer
Farrow to Wean
-F --
Poeilt
Desi'Current gn : t
Caw
Farrow to Feeder
:
Ca aci
P,o
Non -Dairy
Farrow to Finish
Layers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
2K Pullets
Beef Brood Cow
Other
Turke s
Turkey Points
OtherIN
10ther
Discharses and Stream impacts
. 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 DWQ)
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 DWQ)
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 ❑ NA ❑ NE
❑ Yes [:]No
[:]Yes [:]No
❑ Yes ❑ No
❑ Yes No
❑ Yes No
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Page I of 3 21412011 Continued

Facili Number: Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes 0 No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in): _ _ r I
Observed Freeboard (in): p?�
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes K No ❑ 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
0 No
❑ NA
❑ 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 DWQ
7. Do any of the structures need maintenance or improvement?
❑ Yes
Cff No
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
®. No
❑ NA
❑ 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
[Z No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
® No
❑ NA
❑ NE
maintenance or improvement?
11. is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes 25 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). �/y�Ml.�� 1D1'A'`51'rD�
13. Soil Type(s): GUa�xn�._ / j 1) fRr4-
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
to No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
Z No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
No
C] NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
[ No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
[� No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? if yes, check
❑ Yes
No
❑ NA
❑ NE
the appropriate box.
❑ WUP ❑ Checklists ❑ Design ❑ Maps [:)Lease Agreements ❑ Other:
21. Does record keeping need improvement? if yes, check the appropriate box below. ❑ Yes [3 No
❑ 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 R3 No
23. if selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes O—No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 21412011 Continued

]Facility Number: - Date of 1 ns ection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes MA la No
• 25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes ®-No
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
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? [::]Yes Cg No
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
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?
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
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
34. Does the facility require a follow-up visit by the same agency'?
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ Yes ® No ❑ NA ❑ NE
❑ Yes ® No ❑ NA ❑ NE
❑ Yes ® No ❑ NA ❑ NE
❑ Yes ® No ❑ NA ❑ NE
❑ Yes No
❑ Yes ® No
❑ Yes ® No
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Phone: '9'jp- yam` moo
Date: r25:: �N
21412011

rf
ivision of Water Qu`aiity
Facility Number ®- G L OO Division of Soil and Water Conservation 7 j
� Other Agency
Type of Visit: Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
[lesson for Visit: outioe 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: ' fl a Departure Time: p County: ;���. Region: r—A D
Farm Name: C % . '�_ � Owner Email:
Owner Name: Vez Phone:
Mailing Address:
Physical Address:
Facility Contact: ["i-, "I XJ y Title:
1
Onsite Representative: ���� Integrator:
Phone:
Certified Operator: I Certification Number:
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
Design Current Design Current
Design Current
Swine
Capacity Pop. Wet P�otiltry Capacity Pap.
Cattle Capacity Pop.
Wean to Finish
La er
airy Cow
Wean to Feeder
airy Calf
Non -Layer
Feeder to Finish
airy Heifer
Farrow to Wean
Design Current
D Cow
Farrow to Feeder
Dr l'oultr. Ca aci P,o
Non -Dairy
Farrow to Finish
La ers
Beef Stocker
Gilts
Non -La ers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turke s
Other
Turkey Poults
Other
Other
Discharges and Stream Impacts
I . 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 DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
❑ Yes allo [] NA ❑ NE
[:]Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No [] NA ❑ NE
d_ Does the discharge bypass the waste management system? (If yes, notify DWQ) ❑ Yes ❑ No ❑ NA ❑ NE
2. Is there evidence of a past discharge from any part of the operation? ❑ Yes � No ❑ NA ❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters ❑ Yes J;a No ❑ NA ❑ NE
of the State other than from a discharge?
Page I of 3
21412011 Continued

FaciliNumber: - Date of Inspection: 7— 3—;Z_
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes � No ❑ 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): f
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes [ELNo ❑ 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 ❑ NA ❑ 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 DWQ
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 0 No ❑ NA ❑ 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 es No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes g No ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes [g No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 1bs. ❑ 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): _lam/ , //at 1 ®roc l:-� -,-4
13. Soil Type(s): /d��!L�a-r- l )cJO/fD I/ y - -
14, Do the receiving crops differ from those designated in the CAWMP?
[:]Yes
ELNo
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
0 No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
Z No
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
® No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
[allo
❑ NA
❑ NE
Reauired Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
[g No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
® No
❑ NA
❑ NE
the appropriate box.
❑WUP [-]Checklists [] Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. [::]Yes ® No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes [ No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes ® No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 21412011 Condfnued

Facility Number: - fo Date of Inspection: 7-
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes E[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?
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
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?
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
permit? (i.e., discharge, freeboard problems, over -application)
❑ Yes f4No ❑ NA ❑ NE
[:]Yes ®No [:]NA ❑ NE
❑ Yes ® No ❑ NA ❑ NE
❑ Yes 0 No ❑ NA ❑ NE
❑ Yes Q No ❑ NA ❑ NE
31. Do subsurface the drains exist at the facility? If yes, check the appropriate box below. [:]Yes ® No
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes ® No
33. Did the Reviewer/Inspector fail to discuss reviewlinspection with an on -site representative? ❑ Yes No
34_ Does the facility require a follow-up visit by the same agency? [:]Yes No
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone:
❑ NA ❑ NE
❑NA ❑NE
❑ NA ❑ NE
❑NA ❑NE
Date: 7 /'-_' —
2✓412011

x ype of v 1511: Vd' ompuance inspection v operation Review V Structure tvatuation t o Technical Assistance
Reason for Visit: outme O Complaint O Follow-up O Referral Q Emergency O Other Q Denied Access
Date of Visit: !. /�, Arrival Time: Departure Time: / : 5-county:czrL
Farm Name: �Q1� R ray five Owner Email:
Owner Name:Phone:
Mailing Address:
Physical Address:
Facility Contact: r�;i` /� f l P Y Title: e6c--1p k-.'r
7
Onsite Representative:
Certified Operator:
Phone:
Integrator: 4KgK
Certification Number:
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
Region: l�
Design
Current
.
Design Current
Design Current
Swine
Capacity
:.Pop.
Wet Poultry
La er
Capacity Pop.
Cattle Capacity Pop.
DairyCow
Wean to Finish
Wean to Feeder
Non -La er
Ili
DairyCalf
DairyHeifer
Feeder to Finish
Qa
Farrow to Wean
9
4
Design- Cur er tit
D Cow
Farrow to Feeder
D , P,oult ,
Layers
C_ a aei P,o _ __.:,
"'
Non -Dairy
Beef Stocker
Farrow to Finish
Gilts
Non -La ers
Pullets
t;, -
Beef Feeder
Beef Brood Cow
Boars
Turkeys
-
Other
Turkey Puults
Other
Other
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 DWQ)
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 DWQ)
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 allo ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
21 No
❑ NA
❑ NE
❑ Yes
jo No
❑ NA
❑ NE
Page l of 3 21412011 Continued

Facili Number: - Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
No
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No
❑ NA
❑ NE
Structure l Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier:
Spillway?:
Designed Freeboard (in): _ Z 9
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
jo No
❑ 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
tgNo
❑ NA
❑ 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 notify DWQ
7. Do any of the structures need maintenance or improvement?
® Yes
threat,
�Na
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
W No
❑ NA
❑ 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
RNo
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
®No
❑ NA
[] NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes [a No ❑ NA 0 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): —Z4f6 iL e&. ,/ f9li : >6`Sz���` _ --
13. Soil Type(s): 41JIFIf-rIf F / y_Jj,'fb/fC
14. Do the receiving crors differ from those designated in the CAWMP?
❑ Yes
N No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
ayes
❑ No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
5jNo
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
[allo
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
allo
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
[] Yes
(allo
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
allo
❑ NA
❑ NE
the appropriate box_
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes ®..No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and I" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? [:]Yes "No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? D Yes ;qNo
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
[DNA ❑NE
❑ NA ❑ NE
Page 2 of 3 21412011 Continued

r
Facili Number: _ Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes E] No
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes ® No
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 provide documentation of an actively certified operator in charge? ❑ Yes No
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes No
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes ® No
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
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
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface the drains exist at the facility? If yes, check the appropriate box below.
[] Yes No
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CA WMP?
❑ Yes [ No
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes ® No
34. Does the facility require a follow-up visit by the same agency?
❑ Yes ® No
❑ NA ❑ NE
❑NA ❑NE
❑ NA ❑ NE
❑ NA ❑ NE
❑NA ❑NE
❑ NA ❑ NE
❑NA ❑NE
❑ NA ❑ NE
❑ NA ❑ NE
❑NA ❑NE
❑ NA ❑ NE
IComore©ts (rt fer to griestion #) Explain any YES answers and/or any additional recommendations or any 616 ecomments°:
likArawings. ;of:facility ta6etter explain situations (use additional pages as necessary):.:::,
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone:
Date: 91Z
21412011

Type of Visit (Mompliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit C':fo-utine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: Arrival Time: : J a Departure Time: County: Region:
Farm Name: _Ca--�a`. M { 1 �Q/n'`- Owner Email:
lor
Owner Name: i _ y Phone:
T
Mailing Address:
Physical Address:
Facility Contact: r Title: Phone No:
Onsite Representative: Integrator:
Certified Operator: Operator Certific ion Number:
Back-up Operator: Back-up Certification Number:
Location of Farm: Latitude: 0 0 0 6 = Longitude: = n
Design Current
Swine == Capacity Population
Design Current
Wet Poultry . Capacity Population
Design
C>attle Capacity
Current
Population
❑ an to Finish
❑ La er
❑ Dairy Cow
❑ an to Feeder
❑ Non -Layer
I
❑ Daia Calf
® Feeder to Finish @O
❑ Farrow to Wean
❑ Farrow to Feeder"
❑ Farrow to Finish
❑ Gilts
❑ Boars
-_
Other
❑ Other
Dry Poultry .., ..
❑ Non -Layers ers
❑ Nets
❑Pullets
❑ Turke s
❑ Turkey Poults
❑ Other
❑ Dairy Heifer
❑ Dry Cow
❑ Non -Dairy
❑ Beef Stocker
❑ Beef Feeder
❑Beef Brood Co Ai
Number of Structures:
Discharges & 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 DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes. notify DWQ)
2. Is there evidence of a past discharge from any part of the operation'?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
❑ Yes RLNo ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
®,No
❑ NA
❑ NE
❑ Yes
P-No
❑ NA
❑ NE
Page 1 of 3 12128104 Continued

Facility Number: Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Structure 1 Structure 2 Structure 3 Structure 4
Identifier:
❑ Yes MNo ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
Spillway?:
Designed Freeboard (in). t9
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes [K No ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes E� No ❑ NA ❑ NE
through a waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public stealth or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes L.No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes ® No ❑ NA ❑ 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 ❑ NA ❑ NE
maintenance or improvement'?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes 1 No ❑ NA ❑ NE
maintenance/improvement'?
11. Is there evidence of incorrect 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 Area
12. Crop type(s) n,- u 1--l-
13. Soil type(s) Uj
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes ZI No ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? aYes ❑ No ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ? ❑ Yes VL No ❑ NA ❑ NE
17. Does the facility lack adequate acreage for land application? ❑ Yes No ❑ NA ❑ NE
18. Is there a lack of properly operating waste application equipment? ❑ Yes VN.No ❑ NA ElNE
11111
%
w (q ) , :, any other comments.
Use dranwut s of f celtty two b tte�r explain situations. (use gdd do ela a es as necesda Lions orl II"
t
ll r I 1/
v!�Mae-al.
.S%-µ-me!
Reviewer/Inspector Name Phone:
Reviewer/inspector Signature: Date: �� D
Page 2 of " " 12128104 Continued

Facility Number: — (o Date of Inspection
• Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes [ANo ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes '0 No ❑ NA ❑ NE
the appropriate box.
❑ WUP El Checklists ❑Design El Maps ❑Other �,
21. Does record keeping need improvement? If yes, check the appropriate box below. 0-Yes II�Nol�' ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ERWaste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V Rain Inspections ❑ Weather Code
22. Did the facility fail to install and maintain a rain gauge?
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
24. Did the facility fail to calibrate waste application equipment as required by the permit?
25. Did the facility fail to conduct a sludge survey as required by the permit?
26. Did the facility fail to have an actively certified operator in charge?
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
and report the mortality rates that were higher than normal?
30. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately
31. Did the facility fail to notify the regional office of emergency situations as required by
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
33. Does facility require a follow-up visit by same agency?
Additional^Comments aid/or Drawings: ' -
Caw
17,03
s 2v. .
❑ Yes
E? No
❑ NA
❑ NE
❑ Yes
® No
❑ NA
❑ NE
❑ Yes
W No
❑ NA
❑ NE
❑ Yes
ER No
❑ NA
❑ NE
❑ Yes
® No
❑ NA
❑ NE
❑ Yes
1,21 No
❑ NA
❑ NE
❑ Yes
JR[No
❑ NA
❑ NE
El Yes
,ZNo
El NA
El NE
❑ Yes
allo
❑ NA
❑ NE
❑ Yes
5� No
❑ NA
❑ NE
❑ Yes
allo
❑ NA
❑ NE
❑ Yes ® No ❑ NA ❑ NE
Page 3 of 3 12128104

I
Type of Visit compliance Inspection O Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit outine 0 Complaint O Fallow up O Referral O Emergency O Other ❑ Denied Access
Date of Visit: L F Arrival Time: OO I Departure Time: ; County: SgRegion: 1 Q'
Farm Name: Ladd/ I l y �adrn Owner Email:
Owner Name: �d r r I ef V Phone:
Mailing Address:
Physical Address:
Facility Contact: IIII f.� IT, A J JAY Title: A�e.,Le Phone No:
Onsite Representative: 7�•�-� Integrator: �/ilsr✓�/!
Certified Operator: SCE-`-- Operator Certification Number:
Back-up Operator:
Back-up Certification Number:
Location of Farm: Latitude: 0 0 0 t = u Longitude: [::] ° 0 & 0
Desigrt
C>>urrent
Design Current
Design Current
Swine
Capacity
Population
Wet Poultry Cap�itty Population
C•atlle Capacity Population
❑ Wean to Finish
ID Layer
El Dairy Cow
❑ Wean to feeder
10 Non -Layer
I I
El Dairy Calf
Feeder to Finish
0
pry Poultry
❑
❑ Non -Layers
❑ Dairy Heifer
El Dry Cow
❑ Non -Dairy
❑Beef Stocker
❑Beef Feeder
ElFarrow to Wean
❑ Farrow to Feeder
El Farrow Farrow to Finish
❑ Gilts
❑ Boars
❑ Pullets
❑ Beef Brood Cowl
❑ Turkeys
Other
❑ Other
❑ Turkey Poults
❑ Other
Number of Structures: ELI
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
Salo
❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
❑ Yes
❑ No
❑ NA
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
❑ Yes
❑ No
❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
❑ Yes
❑ No
❑ NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
®.No
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
P No
❑ NA
❑ NE
other than from a discharge?
12128104
Continued

Facility Number: Date of Inspection D�
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Structure 1 Structure 2 Structure 3 Structure 4
Identifier:
❑ Yes SNo ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):_
5. Are there any immediate threats to the integrity of any of the structures observed? [:]Yes PjNo ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes [0 No ❑ NA ❑ NE
through a 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 DWQ
7. Do any of the structures need maintenance or improvement? RYes ❑ No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes RNo ❑ NA ❑ 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 [0 No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes f![ No ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes JZ No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 Ibs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
12_ Crop type(s) &e"
13. Soil type(s) jX,,,x
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes ® No ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? [.Yes ❑ No ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ? [:]Yes No ❑ NA ❑ NE
17. Does the facility lack adequate acreage for land application? ❑ Yes No ❑ NA ❑ NE
18. Is there a lack of properly operating waste application equipment? ❑ Yes kNo ❑ NA ❑ NE
Use drawtn s of facility t© Netter explain situations, use"additional a es as riecessar�. any"other comments
Comments (refer to question #): Explain any YES answers and/or any recommendations or,
�*~
g tY P ( P g .. )a
L �
ck_,w,_ Aloes
Reviewer/Inspector Name �1, �ip��331
G r Phone: _
Reviewer/Inspector Signature: Date:

Facility Number: Date of Inspection 774c�_
Required records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes ONO ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes KNo ❑ NA ❑ NE
the appropirate box. ❑ WUP ❑ Checklists ❑ Desig
n ❑ Maps ❑ Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes RjNo ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rain Inspections ❑ Weather Code
22. Did the facility fail to install and maintain a rain gauge?
❑ Yes
Flo
❑ NA-
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
&.No
❑ NA
❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
4No
❑ NA
❑ NE
25. Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
SNo
❑ NA
❑ NE
26. Did the facility fail to have an actively certified operator in charge?
❑ Yes
&No
❑ NA
❑ NE
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
RNo
❑ NA
❑ NE
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
P-No
❑ NA
❑ NE
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
0,No
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
P�No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
31. Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
ONO
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
ONO
❑ NA
❑ NE
33. Does facility require a follow-up visit by same agency?
❑ Yes
10 No
❑ NA
❑ NE
Comments and/or
12128104

Type of Visit g.Compliance Inspection O Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit outine O Complaint O Follow up O Referral O Emergency O Other ❑ Denied Access
Date of Visit: Arrival Time: ' t7 Departure Time: County: Region: -T-TY)
Farm Name: n� e Q/rYV Owner Email:
Owner Name: 1 �110// 174 e 4 f Phone:
Mailing Address:
Physical Address:
Facility Contact:C! ► Title: Phone No:
Onsite Representative: �S �-.�� Integrator: �f d
Certified Operator: Operator Certification Number: %ktaJ
Back-up Operator:
Back-up Certification Number:
Location of Farm: Latitude: ❑ o = 6 = Longitude: = o = 1 0
DesignCu err err nt Design C►nrrent
Swine Cap�3CEtyPop Iahon Wet Poultry Capacity Population
Design Current
C+tittle Capacity Population
❑ Wean to Finish
❑ Wean to Feeder
Feeder to Finish33
❑ Layer
❑ Dairy Cow
❑ Non -Layer
❑ Dairy Calf
YZry.
R
rDry Poultry' :F '�
-
❑
❑ Non -Layers
❑ ❑ Pullets
Turke s
,, El Tur ey Poults
* ❑Other
Dairy Heifer
❑ Dry Cow
❑ Non
❑ Farrow to Wean
El Farrow to Feeder
El Farrow Farrow to Finish
❑ Gilts
-Dairy
El Beef Stocker
❑ Beef Feeder
❑ Boars
❑Beef Brood Cow
Other
❑ Other
Number of Structures:
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
f@ No
❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
❑ Yes
❑ No
❑ NA
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
❑ Yes
❑ No
❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
❑ Yes
❑ No
❑ NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
;&No
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
JO No
❑ NA
❑ NE
other than from a discharge?
Page 1 of 3
12128104
Continued

Facility Number: Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes XS No ❑ 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
[I NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
❑ Yes
® No
❑ NA ❑ NE
through a 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 DWQ
7. Do any of the structures need maintenance or improvement?
❑ Yes
KNo
❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit?
❑ Yes
U No
❑ NA ❑ 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
JR No
❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
J9 No
❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below.
❑ Yes
Wo
❑ 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 Area
12. Crop type(s) !�/
13. Soil type(s) 11`a
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
JR No
❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement?
,0 Yes
❑ No
❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?❑
Yes
I& No
❑ NA ❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
No
❑ NA ❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
[ No
❑ NA ❑ NE
s
Reviewer/Inspector Name �� .; �, TJ� Phone: 9-112 ;r 7
Reviewer/Inspector Signature: Date:
Page 2 of 3 12128104 Continued

Facility Number: Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes J91 No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes O No ❑ NA ❑ NE
the appropiate box. ❑ WUP ❑ Checklists ❑ Design ❑ Maps ❑ Other
21. Does record keeping need improvement'? If yes, check the appropriate box below. ❑ Yes ❑ No ❑ NA ❑ NE
9 Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V Rain Inspections ❑ Weather Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
[2 No
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
E4 No
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
14No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
allo
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
Cl Yes
ENNo
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
[N No
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
R9 No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
D9 No
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30.
At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
CK No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
31.
Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
® No
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
® No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
Jallo
❑ NA
❑ NE
Page 3 of 3 12128104

ivision of Water Quality J1
Facility Number 0 Division of Soil and Water Conservation
- 0 Other Agency
Type of Visit
ompliance Inspection
0 Operation Review 0 Structure Evaluation
0 Technical Assistance
Reason for Visit
outlne 0 Complaint
0 Follow up 0 Referral 0 Emergency
0 Other ❑ Denied Access
Date of Visit: ® Arrival Time: Departure Time: I 11 0 County: Region:
Farm Name: Ifz/•`Z Owner Email:
Owner Name: a rL Phone:
Mailing Address:
Physical Address:
Facility Contact: �ael _ Title: Phone No:
Onsite Representative: -S— Integrator:
Certified Operator: Ste_ Operator Certification Number:
Back-up Operator:
Location of Farm:
Swine
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Boars
Other
❑ Other
Back-up Certification Number:
Latitude: = o = S ='[ Longitude: = o ='
=
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer
❑ Non -La er
Dry Poultry
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ Turkey Poults
❑ Other
Discharges & Stream Facts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
Cattle
Design Current'
Capacity Population
i
❑ Dairy Cow
❑ Dairy Calf
❑ Dairy Heifet
❑ Dry Cow
❑ Non -Dairy
❑ Beef Stocker
❑ Beef Feeder
❑ Beef Brood Co
Number of Structures:;
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
❑ Yes RNo ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
LK No
❑ NA
❑ NE
❑ Yes
0 No
❑ NA
❑ NE
12128104 Continued

r
Facility Number: —
Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
29 No
❑ 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
S
Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): S b
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
q No
❑ NA
❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
❑ Yes
10 No
❑ NA
❑ NE
through a 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 DWQ
7. Do any of the structures need maintenance or improvement?
& Yes
❑ No
❑ NA
❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit?
❑ Yes
[9No
❑ NA
❑ 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
El NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
RNo
❑ NA
❑ NE
maintenance/improvement?
11. is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes 29 No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 1 U% or 10 Ibs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
12. Crop type(s)
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
� No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?[] Yes
No
❑ NA
❑ NE
t 7. Does the facility lack adequate acreage for land application?
❑ Yes
® No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
WNo
❑ NA
❑ NE
Comments (refer to question #): Explain any YES answers and/or any recommendations or any other comments.
Use drawings of facility to better explain situations. (use additional pages as necessary):
Reviewer/inspector Name Rr, Phone: 9ip— J L3- MD
Reviewer/Inspector Signature: Date:

Facility Number: — Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? Yes Peo ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes ® No ❑ NA ❑ NE
the appropiate box. ❑ WUP ❑ Checklists ❑ Design ❑ Maps ❑ Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes ISNo ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rain Inspections ❑ Weather Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
ENNo
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
I No
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
;4 No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
JO No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
UR No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
0 No
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
[3 No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
® No
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30.
At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
0 No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
31.
Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
56 No
❑ NA
❑ NE
General Permit? (iel discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
JB No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
0 No
❑ NA
❑ NE
Comments and/or
12128104

Type of Visit 9-Co—mpliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit 0 Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑Denied Access
Date of Visit:Arrival Time: 1 D Departure Time: ; pD County: PI Region:
Farm Name: V Owner Email:
Owner Name: C ar L L -,cr y Phone:
Mailing Address:
Physical Address: I
Facility Contact: eC4 ► e y Title: Phone No:
Onsite Representative: Integrator:
Certified Operator: Operator Certification: Z&Y /
Back-up Operator:
Back-up Certification Number:
Location of Farm: Latitude: = o = f = {f Longitude: = ° = 1 = u
Design Current
ogulat�on
Wet Poul#ry
DesigpILLurrent
Capacitypulation
Design Current
Cattle Capacity Population
❑ Wean to Finish
❑ La er
1
❑ Daia Cow
❑ Wean to Feeder
❑Non -La er
I
❑ Dairy Calf
LZ Feeder to Finish j D
❑ Dairy Heifer
❑ Farrow to Wean
;_ :.. � .� �.Cow
El
Farrow to Feeder
Discharges &Stream Impacts
1.
Is any discharge observed from any part of the operation?
❑Yes
�KNo
❑ NA
❑ NE
Discharge originated at: ❑Structure ❑Application Field ❑Other
a. Was the conveyance man-made?
❑Yes
01 No
❑ NA
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
❑Yes
4 No
❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
El Yes
� No
❑ NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑Yes
� No
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑Yes
W No
❑ NA
❑ NE
other than from a discharge?
Page 1 of
I2/28/04
Continued

Facility Number: ZE—
Date of Inspection T
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a_ If yes, is waste level into the structural freeboard?
Structure i Structure 2 Structure 3 Structure 4
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
through a waste management or closure plan?
❑ Yes CgNo ❑ NA ❑ NE
❑Yes RNo El NA [I NE
Structure 5 Structure 6
❑ Yes P9 No ❑ N A ❑ NE
❑ Yes 4 No ❑ NA ❑ NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? aYes �No ❑ NA ❑ NE
$. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes ® No ❑ NA ❑ 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 JZ No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes ® No ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below_ ❑ Yes [SNo ❑ 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 Area
12. Crop type(s) a �,rd; ►�
13. Soil type(s) ZV40
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes 1,No Cl NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ® Yes WNo ❑ NA ❑ NE
1
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ? ❑ Yes El No ❑ NA ❑ NE
17. Does the facility lack adequate acreage for land application? ❑ Yes Do No ❑ NA ❑ NE
18. Is there a lack of properly operating waste application equipment? ❑ Yes [ANo ❑ NA ❑ NE
AL
nKd d
Reviewer/Inspector Name
m p,..�bD
-��f 1/� L _ Phone: %O
Reviewer/Inspector Signature: Date:
Wage 1 aJ 1 12128104 Continued

Facility Number: — Date of Inspection jD-- O 6
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes 0 No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes jo No ❑ NA ❑ NE
the appropriate box.
❑ WUP El Checklists ❑Design El Maps ❑Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes [No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rain Inspections ❑ Weather Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
® No
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
29 No
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
P No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
M-No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
R No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
RNo
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
E No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
RNo
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30.
At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
54 No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
31.
Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
allo
❑ NA
❑ NE
General Permit? (ieI discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
� No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
XjNo
❑ NA
❑ NE
Additional Comments and/or Drawings: �.
i
7
Page 3 of 3 I2/28/04

type of Visit • Compliance Inspection U Operation Review O Structure Evaluation U Technical Assistance
Reason for Visit 40 Routine O Complaint O Follow up Q Referral O Emergency O Other ❑ Denied Access
Date of Visit: -/ o Arrival Time: Departure Time: �� County: ��esorl Region: F'P>7
Farm Name: Carf kk1 e GucOwner Email:
Owner Name: _� ! R=' Phone: 9/d ' �3-2 ' )2 j
Mailing Address: �i.Z fi _ n m a.x a y g _ iyC ere lA A(( —
Physical Address:
Facility Contact: C6111 �t�%��, Title:
Onsite Representative: C if n
Certified Operator: C ale
Back-up Operator:
Location of Farm:
Swine
Latitude: = e
Phone No:
Integrator: _491C" .4 n¢ �.d1�i. r ,,
Operator Certification Number:
Back-up Certification Number:
0 Longitude: ❑ ° = ' 0
Design Current Design Current
Capacity 'Population Wet Poultry Capacity Population
❑ La er
} ❑ Non -La et
❑ Wean to Finish
❑ Wean to Feeder
Dleeder to Finish
0
❑ Farrow to Wean
❑ Farrow to Feeder
s
❑ Farrow to Finish
❑ Gilts
❑ Boars
Other
❑ Other - —
-Dry Poultry
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ Turke Poults
❑ Other
Discharges & 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?
Design Current `J
Cattle Capacity Population>,
❑ Daia Cow
❑ Daia Calf
❑ Dairy Heifei
❑ Dry Cow
❑ Non -Dairy
❑ Beef Stocker
❑ Beef Feeder
❑ Beef Brood Co
Number of Structures
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
e. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (if yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
❑ Yes 2 No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
Rio
❑ NA
❑ NE
❑ Yes
el10
❑ NA
❑ NE
12128104 Continued

Facility Number: I? L Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Structure 1 Structure 2 Structure 3 Structure 4
Identifier: [
Spillway?: r7 0
Designed Freeboard (in): moo, y ��
Observed Freeboard (in):y'yy
5. Are there any immediate threats to the integrity of any of the structures observed?
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
through a waste management or closure plan?
❑ Yes ONo ❑ NA ❑ NE
❑Yes El No El NA El NE
Structure 5 Structure 6
❑ Yes Qof-4o ❑ NA ❑ NE
❑ Yes ❑'No ❑ NA ❑ NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes [TNo ❑ NA ❑ NE
S. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes
9 No
❑ NA ❑ NE
(Not applicable to roofed pits, dry stacks and/or wet stacks)
9. Does any pa- of the waste management system other than the waste structures require ❑ Yes
[XNo
❑ NA ❑ NE
maintenance ,)r improvement?
Waste A P-Pbc5 :ion
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes
ZNo
❑ NA ❑ NE
maintenance/improvement'?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes
O No
❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 Ibs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drifi ❑ Application Outside of Area
( So A3s
12. Croptype(s) ✓�srw/� 4ira,'n . Lee,-0 6
13. Soil type(s) l.a 6�
_ —
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes
M14o
❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes
[-Vo
❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination: ❑ Yes
❑ No
❑ NA aNE
17. Does the facility lack adequate acreage for land application? ❑ Yes
❑ No
❑ NA [ENE
18. Is there a lack of properly operating waste application equipment? ❑ Yes
21' o
❑ NA ❑ NE
I/ e tf i'E avrr5rrr.� cry` :1 �o�i.,nrG! o n 6f,'„ 9 r e r,.l rn wrL er G kars
Reviewer/Inspector Name �! Q ' Phone: 41 —/ 7.ro
ReviewerfInspectorSignature: Date: y /3-Os-^
1"110/ulf %_unionueu

Facility Number: Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? 2 es ❑ No ❑ NA ❑ NE
20.
Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
YNo
❑ NA
❑ NE
the appropirate box. ❑ D ElM❑ Qtef
❑ W ❑ Che fists
21.
Does record keeping need improvement? If yes, check th a proriate box below.
❑ Yes
❑'Po
El NA
❑ NE
❑ ❑ ❑aVmte-�❑ S a ysis ❑
❑ Affintieti-errifflMo
❑a� ❑ Sfe� ❑ Grep-y� ❑ ❑
❑4W-a+n-CmlL-
22.
Did the facility fail to install and maintain a rain gauge?
lema
[�es WTo
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?/Vm4g
es g o
❑ NA
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
QrNo
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
[9'5o
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
G2-fgo
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
❑ No
❑ NA
2VE
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes 014o ❑ NA ❑ NE
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
E31�o
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
2'No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
31. Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
RRO
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
U-NO
❑ NA
❑ NE
33. Does facility require a follow-up visit by same agency?
❑ Yes
ONo
❑ NA
❑ NE
I7'. , l
�arn � a,.9t Leas 6ro�s� I 10/G42`­r r40/o e
Gtf Svon a+s Pd4SS;6!r
001"16 i0 leae-e G
Cory oT s yt Se-rvey Q,,v/
1 rr.'g.,.►�r;,,, e9Gp,rni ca 4ru /'�C45t' Lc/ork rd CSfa 6ris� 900� �/GfS Corr
1711 bare Gt/Yaf groaw�
�O Or�,�� erdSer„r
12128104

IType of Visit • Compliance Inspection O Operation Review O Lagoon Evaluation
Reason for Visit 40 Routine Q Complaint O Follow up O Emergency Notification O Other ❑ Denied Access
F_ Facility Number Date of Visit: li Tune:
O Not O erational O Below Threshold
14Permitted 13Certified 0 Conditionally Certified 0 Registered Date Last Operated or Above Threshold:
Farm Name: ..... ..�r. � �'1 .. � .ftt!� .._ _ . _ _.._..... County:
Owner Name: _.......... �; leNo:ZZL,3
....W_...—t.�_..._.... _ rr._..... ._..... - Phone ............_.. �c.� _.....
Mailing Address:.. �i� .. �.l� t�l+T. Herr ��s ------- _Z$��_
Facility Contact:��, . �..�.!G Title: Phone No:
......... _... _............ ..-�_ _.._ _.
Onsite Representative:..r� ..„ . _.11� Integrator:
............ ............ .
Certified Operator:._.__.,,,,..`.. . _ Operator Certification Number:,_.___,9!&L._.
Location of Farm:
IS Swine ❑ Poultry Q Cattle ❑ Horse Latitude �` �` r �« Longitude • ` "
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation? ❑ Yes KNo
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made? ❑ Yes ❑ No
b. If discharge is observed, did it reach Water of the State? (If yes, notify DWQ) ❑ Yes ❑ No
c. if discharge is observed, what is the estimated flow in gaUmin'?
d. Does discharge bypass a lagoon system? (If yes, notify DWQ) ❑ Yes ❑ No
2. Is there evidence of past discharge from any part of the operation? ❑ Yes KNo
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes J,No
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway ❑ Yes KNo
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: __....._.�...._. _ _ ...... ...�_..
Freeboard (inches): 2-8
12112103 Continued

Facility Number: $L — b Date of Inspection
5. Are there any immediate threats to the integrity of any of the structures observed? (iet trees, severe erosion, ❑ Yes JC No
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or [] Yes ELNo
closure plan?
(If any of questions 4-6 was answered yes, and the situation poses an
immediate public health or environmental threat, notify DWQ)
7. Do any of the structures need maintenance/improvement? ❑ Yes KNo
8. Does any part of the waste management system other than waste structures require maintenancerimprovement? ❑ Yes No
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level ❑ Yes No
elevation markings?
Waste ADulication
10. Are there any buffers that need maintenancelimprovement? ❑ Yes [,No
11. Is there evidence of over application? If yes, check the appropriate box below. ❑ Yes :,No
❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload ❑ Frozen Ground ❑ Copper and/or Zinc
12. Crop type &e+rrvt'J"C, s �� , Sct .e�3
w n1nCCA _.
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)? ❑ Yes EqNo
14. a) Does the facility lack adequate acreage for land application?
b) Does the facility need a wettable acre determination?
c) This facility is pended for a wettable acre determination?
15. Does the receiving crop need improvement?
16, Is there a lack of adequate waste application equipment?
Odor Issues
17. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below
liquid level of lagoon or storage pond with no agitation?
18. Are there any dead animals not disposed of properly within 24 hours?
19. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt,
roads, building structure, and/or public property)
20. At the time of the inspection did the facility pose an odor or air quality concern? If yes, contact a regional
Air Quality representative immediately.
❑ Yes [2 No
❑ Yes 19 No
❑ Yes Klo
❑ Yes BNo
❑ Yes JjNo
❑ Yes ❑ No
❑ Yes CANo
❑ Yes Jq No
❑ Yes ANo

Facility Number: 82 _ 20 Date of Inspection �- 0
Required Records & Documents
21. Fail to have Certificate of Coverage & General Permit or other Permit readily available?
22. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUV!checklisW,'Od'esigtl"mapy etc.)
23. Does record keeping need improvement? If yes, check the appropriate box below.
❑ Waste ApplicatioV❑ Freeboard' ❑ Waste Analy4K' ❑ Soil Sampling
24. Is facilitynot in�com fiance with an applicablesetback ccriteria in effect at the time of design?
P y aPP
25. Did the facility fail to have a actively certified operator in charge?
26. Fail to notify regional DWQ of emergency situations as required by General Permit?
(ie/ discharge, freeboard problems, over application)
27. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
28. Does facility require a follow-up visit by same agency?
29. Were any additional problems noted which cause noncompliance of the Certified AWMP?
NPDES Permitted Facilities
30. Is the facility covered under a NPDES Permit? (If no, skip questions 31-35)
31. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
32. Did the facility fail to install and maintain a rain gauge?
33. Did the facility fail to conduct an annual sludge survey?
34. Did the facility fail to calibrate waste application equipment?
35. Does ecord keeping for NPDES required forms need improvement? If yes, check the appropriate box below
Stocking Forte ❑ Crop Yield Fort❑ Rainfall❑ Inspection After I" Rainj/'
❑ 120 Minute Inspectiotn Annual Certification Foray
❑ Yes VLNo
[]Yes ]RNo
❑ Yes J9 No
❑ Yes P,No
❑ Yes UWo
❑ Yes CK No
❑ Yes C5 No
❑ Yes 5& No
❑ Yes K No
KYes ❑ No
❑ Yes RNo
❑ Yes J9 No
❑ Yes KNo
JAYes ❑ No
❑ Yes ff No
P-LNo violations or deficiencies were noted during this visit. You will receive no further correspondence about this visit.
ddltloIIal COrtimStitS Snd/or Drawings s x'�m °_,. ;3 " _s _ :tee x � i
23 . p[r. R: l d:A v►of So -vk a-,4ys S fvr: S i �a i••�
q "+c VLQ G. "rj +—+t'
w, t1 b e. OJJ-e-J as 5 trcx a.z P crs s : is k ,
31 . VJO r F.1t Am �e P 1a G e. tZ7►+ r� Ipr�.lf� r � �acl L- a G¢.v+ �+ Sri���
34. Mr. R; L41 Pt.ccwc"d I-t4 cX11'Or`a--+&VL L►� r+�S G�f b�-r -4 -i'e was K-o
&O -k; c" 4" If mi, . re-c-vr c- . we +0
ck, qrl_a-c e . c F 't E,* p r v c ag rc- o,—A 4-eS A+-5 of `te CaJ�A r" cr,,,
Sr. DaOC c k,a O.r^,e a►.'- 'Ka. k-.aUS 4 QV- v�44 V.
�-c�s . J
12112103

Site Requires Immediate Attention: NO
Facility No. 9 2 - z. &6
DIVISION OF ENVIRONMENTAL MANAGEMENT
ANIMAL FEEDLOT OPERATIONS SITE VISITATION RECORD
Farm Name/Owner: R
Mailing Address: Z z. p
County:. . t3,
Integrator: Zj k 64r_ r,,. -_
On Site Representative:_ _,►
Physical Address/Location: AFL,
DATE: -7- "Z--7 , 1995
Time: ft- % 35_
Phone: o -
— &t I&C-d teR15 QZ_-%Ttg" 3 0 Pi S 1L' 11011---
Type of Operation: Swine ✓ Poultry Cattle
Design Capacity: z �:Jj 6 Number of Animals on Site: 7=59a
DEM Certification Number: ACE DEM Certification Number: ACNEW
Latitude: Y Longitude: ° n_ ' 7z
Circle Yes or No
Does the Animal Waste Lagoon have sufficient freeboard of 1 Foot + 25 year 24 hour storm event
(approximately I Foot + 7 inches) a or No Actual Freeboard: 3 Ft. 15 Inches
Was any seepage observed from the a oon(s)? Yes or �Vo Vas any erosion ob rved? Yes orQ
Is adequate land available for spry ? ( r No Is a cover crap adequate? or No
Crop(s) being utilized: Go^ ,cL r-.-. #A -
Does the facility meet SCS minimum setback criteria? 200 Feet from Dwellings? or No
100 Feet from Wells? De or o
Is the animal waste stockpiled within 100 Feet of USGS Blue -Line Stream? Yes or o
Is animal waste land applied or spray irrigated within 25 Feet of a USGS Map Blue Line: Yes or
Is animal waste discharged into water of the state by man-made ditch, flushing system, or other
similar man-made devices? Yes orCo)If Yes, Please Explain.
Does the facility maintain adequate waste management re ds (volumes of manure, land applied,
spray irrigated on specific acreage with cover crop)? Ye or No
Additional Comments:
Sic K, R,_
Inspector Name
Signature
cc: Facility Assessment Unit Use Attachments if Needed.

Ax=Hu, UP-sst bQ=aZ2QW yJ AN CZ7tTx7ICATIom roR xxK oil, LY?A =D FKEDLoTS
Please ratUZS the o=RylOt I4't" to the Division of gavironm utal JE=Agemeat at
the address oa the mover" 44" 09 this farm.
Name of farm (Ploprint)
Address: . 1�.s_. 1. 1 AV !n
ti C l - Phone No .: 7 !O - q3 z - 7-1 - 7- 3
County; - SArh %-Ij
Farts location: Latitude and Longitude: O`f//' OT`f/n /%. 3e_~ (required) . Also,
please attach a copy of a county road. map with location identified.
Type of operation (swine, layer, dairy, etc..)= ►JE
Design capacity (number of animals): - 2 5 D
Average size of operation•(12 month population avg.): ID 3 T-0
Average acreage needed for land application of waste (acres)t 2 z-.o .4a.[ it.S
aessssaasassM>wssa aaasasasssasassassssssassasasasaassarKrrrs:rsaasassaassas>•awssais
Technical Sp�cialiit Certification
As a technical specialist designated by the North Carolina soil and Water
Conservation Commission pursuant to 15A NCAC 6F - 0005, I certify that the new or
expanded animal waste management system as installed for the farm named above
has an animal waste management plan that meets the design, construction,
operation and maintenance standards and specifications of the Division of
Environmental Management'and the USDA -Soil Conservation Service and/or the North
Carolina soil and water Conservation Commission pursuant to 15A NCAC 2H.0217 and
15A NCAC 6F .0001-.0005. The following e7 events and their corresponding minimum
criteria-haue-been verified by me or other designated technical specialists and
are included in the plan as applicable: minimum separations (buffers); liners or
equivalent for lagoons or waste storage ponds; waste storage capacity; adequate
quantity and amount of land for waste utilization (or use of third party); access
or ownership of 'proper waste application equipment; schedule for timing of
applications; application rates; loading. rates I and the control of the discharge
of pollutants from stortawatar runoff events less severe than the 25-year, 24-hour
storm.
Name of Technical
Affiliation
Address (Agency)
at ( Please Print) AAA
k
Phone No. 9+O - 'rS L -
Signature: Date: `�- !- `�1`_
A,
ax:asa=mZmasaaaa e s a as EY6 man manes no warsa sa a aria= aaaaaaaaasaasaaasa asaas
Owuer/Xanager Agreement
I (we) understand the operation and. maintenance procedures established in the
approved animal waste management plan for the farm named above and will implement
these procedures. I (we) know that ,any additional expansion to the existing
design capacity of the waste treatment.and storage system or construction of new
facilities will require a new certification to be submitted to the Division of
Environmental Management before the new animals are stocked, I (we) also
understand that there must be no discharge of animal waste from this system to
surface waters of the state either through a man-made conveyance or through
runoff from a storm event less severe than the 25-year, 24-hour storm. The
approved plan will be filed at the farm and at the office of the local Soil and
Water Conservation District.
Name of Land nar.2ase
Signature: 41
Name of manager, if different from
CAcI1z;1r,
Date: q -
r (Please print):
Signature: Date:
;cote: A change in land .ownership requires notification or a new certi€iration
(if the approved plan is changed) to be submitted to the Division of
Environmental Management within 60 days of a title transfer.
DEM USE ONLY:ACNr--W#
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