820268_INSPECTIONS_20171231

NORTH CAROLINA .�
Department of Environmental Qual

r '1 AT
2i1
■ YNc ut V XMLe %V % uut �nucc ivaNccawu _! %_1PVUat1VU aCVICIV %/ OU UCMUC [.' VatUat1UU V t ccunical P►"ntUUUC
Reason for Visit: Routine O Complaint O Follow-up O Referral O Emergency O Other Q Denied Access
Date of Visit: _3D Arrival Time: cv p Departure Time: , County: UY Region:t
Farm Name: �� i 4� 1 w n ".6. [ j Owner �Email:
—'
Owner Name: r I Phone:
Mailing Address:
Physical Address:
Facility Contact: J
Onsite Representative:
Certified Operator:
1(
Title: Phone:
Integrator:
Certification Number:
Back-up Operator:
Location of Farm: Latitude:
Certification Number:
Longitude:
Design
Current
Design
Current
= . Design Current
Swine
Capacity
Pop.
VVet Poultry
Capacity
Pop.
Cattle Capacity Pop
11
Wean to Finish
La er
Dairy Cow
Wean to Feeder
Nan -La er
Dairy Calf
Feeder to Finish
&0
q�
Dairy Heifer
Farrow to Wean
Design
Current
Dry Cow
Farrow to Feeder
D . Point ;
Ca act
P,o
Non-Dai
Farrow to Finish
La ers
Beef Stocker
Gilts
Non -La ers
Beef Feeder
Boars
Pullets
I
lgeefBroodCow
Turkeys
Other
,.;
Turkey Poults
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 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 NA ❑ NE
❑ Yes ❑ No E3-NA ❑ NE
❑ Yes ❑ No Q-N-A-❑ NE
❑ Yes
❑ No
E5 NA
❑ NE
❑ Yes
J -No
❑ NA
❑ NE
❑ Yes
�o
❑ NA
❑ NE
Page l of 3 21412015 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 — ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No [a-N-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 Q 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 healtb or environmental
threat, notify DWR
7. Do any of the structures need maintenance or improvement?
❑ Yes
ill-Mo- ❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
�o ❑ NA
❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
it
9. Does any part of the waste management system other than the waste structures require
❑ Yes
[ZLNo- ❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
[� o ❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes D-IQo ❑ 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): ,� C✓`t1'� L�l� �. S ��
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes ❑s 'No ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes [3 '`10 ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes No ❑ 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 u No
❑ Yes [][No
❑ NA ❑ NE
❑NA ❑NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes [ hio ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes fo ❑ 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 allo
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? [:]Yes [:�No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes L�] No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
[DNA ❑ NE
❑NA ❑NE
Page 2 of 3 21412015 Continued

Faclli Number: - Date of Inspection: -1 C' .
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes
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?
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)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
EWo' ❑ NA ❑.NE
C 15o ❑ NA ❑ NE
❑ Yes QTo ❑ NA ❑ NE
❑ Yes [D-Ko-_ ❑ NA ❑ NE
❑ Yes io ❑ NA ❑ NE
❑ Yes P,No ❑ NA ❑ NE
❑ Yes No
❑ Yes No
❑ NA [] NE
❑ NA ❑ NE
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes F-1,N6 ❑ NA ❑ NE
33. Did the Reviewer/Inspector 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 [3No ❑ NA ❑ NE
Reviewer/Inspector Signatur
Page 3 of 3
Date:
214112015

,/. Division of Wate"r�Resources
Facility Number - �' Division of Soil and Wster Conservation
Q Other Agency
Type of Visit: Compliance Inspection O Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit: O Routine O Complaint O Follow-up Q Referral Q Emergency Other Q Denied Access
Date of Visit: Arrival Time: Departure Time: ' /. County: Region:
Farm Name: �;�/fJ� ��1 %� gt��Vr-P-L Owner Email:
Owner Name: GJ/�,'d., QWr Phone:
Mailing Address:
Physical Address:
Facility Contact: ��°an �4lC�ti'%� Title: Phone:
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Integrator:
Certification Number:
Certification Number:
Longitude:
' Des><gn CarreAt
Design
.Curren#
Des ign Current
Swine Ca aci Po
IP h' F•
Wet Poult . Ca aci
rY P h'
Po P
Cattle Ca aci Po
P h' P•
.
milli.
La er
.
to Finish
DairyCow
Ran
an to Feeder
Non -La er
DairyCalf
der to Finish'
DairyHeifer
Des>tgn Current=
row to Wean
D Cow
row to Feeder
D' "' P,oulf , Ca ac- P,o
Non -Dairy
row to Finish
Layers
Beef Stocker
ts
Non -Layers �'
Pullets
Turke sher
Beef Feeder
Beef Brood Cow
Turke PouIts
er
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 DWR)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWR)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
[:]Yes [:]No ❑ NA E]-NE
[:]Yes 0 No ❑ NA [D'NG
❑ Yes ❑ No ❑ NA E3-'NE
❑Yes
[:]No
❑NA
[]-NE
❑ Yes
❑ No
❑ NA
B-TtE
❑Yes
❑No
❑NA
[�
Page 1 of 3 21412015 Continued

Facili Number: L Date of Inspection:
Waste Collection & Treatment
• 4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes [ o
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No
Structure l Structure 2 Structure 3 Structure 4
Identifier:
Spillway?: _
Designed Freeboard (in): _ C
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
(i.e., large trees, severe erosion, seepage, etc.)
❑ NA ❑ NE
❑ NA ❑ NE
Structure 5 Structure 6
❑ Yes ❑ No [] NA �
6. Are there structures on -site which are not properly addressed and/or managed through a ❑ Yes ❑ No
❑ NA
FINE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWR
7. Do any of the structures need maintenance or improvement? [:]Yes ❑ No
❑ NA
[ E
8. Do any of the structures lack adequate markers as required by the permit? [] Yes [:]No
❑ NA
EJ-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
[Q-NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes ❑ No
❑ NA
[aNE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. [—]Yes [-]No
❑ NA
[3-NEE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes ❑ No ❑ NA �E
15. Does the receiving crop and/or land application site need improvement? ❑ Yes ❑ No [] NA [3-NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes ❑ No [] NA E3-I_E
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 E:J�E
❑ Yes ❑ No ❑ NA []-AIF
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes ❑ No ❑ NA EEF E
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes ❑ No ❑ NA ❑.IE
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 [zLNE
❑ Weather Code
❑ Sludge Survey
❑ NA NE
❑ NA []-NE
Page 2 of 3 21412015 Continued

L
Racili Number: 4L - &D Date of Ins ection: --/
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes ❑ No
r
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
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?
❑ NA ❑'NE
❑ NA IE
❑ NA ❑ <E
❑ NA B-9'E
❑Yes ❑No ❑NA Q`-JE
❑ Yes ❑ No ❑ NA D-Nr-
❑ Yes ❑ No ❑ NA EJ-Iq
❑ Yes ❑ No ❑ NA [D-NE^
[—]Yes ❑ No ❑ NA ❑44'1'
❑ Yes ❑ No ❑ NA ❑-3�di✓
❑ Yes ❑ No ❑ NA
Comments (refer to question 9): Explain any YES answers and/or any additional recommendations or any other cornrneuts.
Use drawingsof�facili to better explain situations use additional lE"
ty p ( pages as necessary}.
Reviewer/Inspector Name: �lf� �u�/�� ��i� W N i Phone:
Reviewer/Inspector Signature: Date:l_� G)�
Page 3 of 3 21412015

Type of visit. t-l:om dance Inspection V vperatton xeview V Ntructure Evaluation V 'l eennlcal Assistance
Reason for Visit: (Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: Departure Time: ounty:
fl �� U
�JFarm Name: W OL [' (,t,4__�Y/ Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact: b) a k
Onsite Representative: 1
Certified Operator:
Back-up Operator:
Title:
Phone:
Region
Phone:
Integrator: Al'`"
Certification Number: to qW
Certification Number:
Location of Farm: Latitude: Longitude:
Design Current _,NW7 OMER Current = g "' UI' �! Design Current
Swine Capacity Pop. Wet Poultry Capacity Pop Cattle Capacity Pop.
.
.
Wean to Finish
La er
-_
Dairy Cow
Wean to Feeder
Non -Layer
Dairy Calf
Feeder to Finish
- �,'�Desisign Current z�,�,
D . P,oult . -8 actt} Po .,
Dairy Heifer
Farrow to Wean
D Cow
Farrow to Feeder
iry
Farrow to Finish
Layers
Beef Stocker
Beef Feeder
Gilts
Non -Layers
`=
Boars
Pullets
Turkeys
Beef Brood Cow
IMI Other
Turkey Poults'
Other I
10ther
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)?
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 �o ❑ NA ❑ NE
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes Fi No
[:)Yes allo
EJ�A ❑ NE
[2�NA ❑ NE
[ff'NA
❑ NE
❑ NA
❑ NE
❑ NA
❑ NE
Page 1 of 3 21412015 Continued

[Facility Number: DateTof Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes [1 __E] NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ON o 0_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
L2fiTo
❑ 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
EfNo
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
0 Yes
ER'No
C] 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
�
[El o
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? I f yes, check the appropriate box below. ❑ Yes 0 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): e rN, [�, Sy0 T
13, Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
15. Does the receiving crop and/or land application site need improvement'?
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
the appropriate box.
[]Yes
FEj o
❑ NA
❑ NE
❑ Yes
Io
❑ NA
❑ NE
[:]Yes
Io
❑ NA
❑ NE
[:]Yes L2 o ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
❑ Yes [;3-7q'o ❑ NA ❑ NE
❑ Yes [;I -No ❑ NA ❑ NE
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease A17, eements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes EEM
❑ 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 E5'No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? [:]Yes 0 No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 21412015 Continued

Facillty Number: Date of lnsoection:
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
-' ❑ NA
❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check
❑ Yes
[ ❑ 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
�A}.6 ❑ NA
❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
❑ Yes
E] 1 1O ❑ NA
❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
ED Wo
❑ NA ❑ NE
and report mortality rates that were higher than normal?
24. At the time of the inspection did the facility pose an odor or air quality concern?
[:]Yes
�Io
❑ 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
Q'<o
❑ 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
[3'1io
❑ NA ❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
2Ff o
❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
8'�lo
❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
2"No
❑ NA ❑ NE
Comments (refer to question #): Explain any YES answers andlor,aby additional recommendations or=any other comments. "
Use drawings of facility to better explain situations (useaddition a1z pages as necessary).
[.3 -- t 6
r
Reviewer/Inspector Name
Reviewer/Inspector Signature:
Page 3 of 3
0-3 -R51 1
Phone: q3�33M
Date:13
21412015

I iqs
Type of Visit: ®'Co liance Inspection V Operation Review Q Structure Evaluation Q Technical Assistance
Reason for Visit: Routine Q Complaint 0 Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit: I I.yQ�[ kP Arrival Time: d1 l� Departure Time: d
Farm Name: r j j L yam.fj L- � Owner Email:
Owner Name: ► L i �� _ Phone:
Mailing Address:
Physical Address:
Facility Contact: to % t VA 1
Onsite Representative: It
Certified Operator:
County:
Region:
Phone:
P) 13
Certification Number: 0(` '( "a l3
Integrator:
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
Design Current
Design
Current
Design
Current
Swine Capacity Pop.
Wet Poultry
Capacity
Pap.
Cattle oacity
Pop.
Wean to Finish
La er
Dairy Cow
Wean to Feeder
Layer
Dairy Calf
Feeder to Finish
.:...
�,�..e
Dairy Heifer
Farrow to Wean
Design
Dry Cow
Farrow to Feeder D , foul Ca aci P,o
Non -Dairy
Farrow to Finish
Gilts
Layers
Non -Layers
Beef Stocker
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turkeys
Other
Turkey Poults
Other
Other
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
RrNo
❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
[—]Yes
[—]No
LEJ K
❑ NNE
b. Did the discharge reach waters of the State? (If yes, notify DWR)
❑ Yes
❑ No
[3-N'X-
❑ 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 DWR)
❑ Yes
❑ No
[J NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
[] "o
❑ 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 I of 3 21412014 Continued

Facility Number: Date of Inspection.- I it ✓
Waste Collection & Treatment
4. is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes E+Nv— ❑ NSA ❑ 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?
(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 D-No ❑ NA ❑ NE
❑ Yes CQ❑ 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 Io ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes [. t 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 No ❑ NA ❑ NE
maintenance or improvement?
Waste Aonlication
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes [�Ko ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes [J<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 W4;V11
❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12.Cro T es: �01p (��'k S
13. Soil Type(s): 1� �.04-4A_ (
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
[ o
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
[3 ""'
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
D Yes
L3,1`6
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
[]Ko
❑ 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
[e-No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
E; 10
❑ 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 1 " Rainfall Inspections ❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes eNo ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? [:]Yes dNo ❑ NA D. NE
Page 2 of 3 21412014 Continued

[Fidlity Number: Ot Date of Inspection-:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes L3"'c
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes Q-o
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 fist survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge? ❑ Yes E No
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes Mo
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes [ o
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 [2-No
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 [ rNo
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes fNo
33. Did the Reviewer/inspector fail to discuss review/inspection with an on -site representative? ❑ Yes [111jo
34. Does the facility require a follow-up visit by the same agency? ❑ Yes FZ/No
Reviewer/inspector Signature:
Page 3 of 3
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑NA ❑NE
❑ NA ❑ NE
❑ NA ❑ NE
Dater
14�_Tk
2/4 OI4

4.77%
(Type of Visit: )U Compliance Inspection V Operation Review () Structure Evaluation V Technical Assistance I
Reason for Visit: (YRoutine 0 Complaint 0 Follow-up 0 Referral 0 Ememencv 0 Other 0 Denied Access
Date of Visit: Arrival Time: 10 Departure Time: County: S Region:
Farm Name: W i �..�1 ��w Owner Email:
Owner Name: tj C,) 1�r Phone:
Mailing Address:
Physical Address:
Facility Contact: tj r �—' C.J Title: (9c')kjoL Phone:
Onsite Representative: i� Integrator:
Certified Operator: Certification Number: 8
Back-up Operator:
Location of Farm:
Latitude:
Certification Number:
Longitude:
Design Current
Swine Capacity Pap.
Wean to Finish
Wet Poultry
La er
Design
Capacity
Current
Pop.
Design Current
Cattle Capacity Pop.
D ' Cow
Wean to Feeder
-Layer
Design
Ca aci
Current
P,o
D ' Calf
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
S i'
D . P.oul
Layers
D ' Heifer
D Cow
Non -Dairy
Beef Stocker
Non -Layers
Beef Feeder
Bilts
oars
I
Pullets
I
jBeef Brood Cow
Other,
Other
Turkeys
Turkey Poults
Other
Discharges and Stream Imnacts
l . 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? ❑ Yes ❑ No E NA ❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWR) [:]Yes [:]No U 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 DWR) [:]Yes [:]No NA ❑ NE
2. Is there evidence of a past discharge from any part of the operation? [:]Yes ❑ 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 21412014 Continued

. Fac' ' Number: jDate of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
[!I-No]n NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No 0 1TA_ ❑ 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
❑ 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
[B-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
[D-1To— ❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the pen -nit?
❑ Yes
Q oo ❑ 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
0 Yes
[0,?o ❑ NA
❑ NE
maintenance or improvement?
Waste Ai3plication
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
[:p4o ❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes I3"1"° ❑ 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): IR irv-i) cc& 5-(� -0
13. Soil Type(s): LIZ 1. 1 &-"qLt�Vl
14. Do the receiving crops differ from those designated in 1he CAWMP?
15. Does land improvement?
❑ Yes
Yes
No
6Flo
❑ NA
NA
❑ NE
NE
the receiving crop and/or application site need
❑
0
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
o
❑ NA
0 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
�' i�o
❑ NA
❑ NE
Required Records & Documents
facility
19. Did the fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
C;31<o
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
_ _
0 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 DCo 0 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 dNo 0 NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes eNo ❑ NA 0 NE
Page 2 of 3 21412014 Continued

Facili Number: 113ate of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes [}-NSA ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes ❑-N�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 No ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes No ❑ NA ❑ NE
Other lssues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes E] o ❑ 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 D "'o ❑ 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
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWW? ❑ Yes
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? [] Yes
34. Does the facility require a follow-up visit by the same agency? ❑ Yes
No ❑ NA ❑ NE
Er -No ❑ NA ❑ NE
No ❑ NA ❑ NE
No ❑ NA ❑ NE
Comments (refer to question ft Explain any,YES answers and/or any additional recommendations or, any other c > ments
Use drawings of facility to better explain situations (use additional pages as necessary).
GJ
ReviewerlInspector Name: t 4l Phone: � ` 3
Reviewer/Inspector Signature: Date:
Page 3 of 3 21412014

Type of Visit: ompliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: O tiooutine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: ' D� Departure Time: ! D County: s Region: F/�a
Farm Name: j,(% f l i..� �� w *�I ( rid JrY�.� Owner Email:
Owner Name: W-( I l ' o- .. — `7�t r� i Phone:
Mailing Address:
Physical Address:
Facility Contact: Wi) ,a--- f �Dw�.j I Title: gw/n Phone:
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Integrator:
Certification Number: 1 f y�
Certification Number:
Longitude:
III Design Current
Swine Capacity Pop.
Design= Currept
FW.et Pot Capacity Pop.
Design Current
Cattle Capacity Pop.
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Layer
DairyCow
DairyCalf
Non -Layer
j�
Design - Current
D . P,oul Ca aei $o
DairyHeifer
D Cow
Non -Dairy
Farrow to Finish
I
Layers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Beef Brood Cow
�. ,...
Boars
Pullets
-
Other
Other I
z
Turkeys
-Turkey Poults
10ther
Discharges and Stream Impacts
1. 1s 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 [XVo ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No
[:]Yes E&No
❑ Yes ®, No
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Page 1 of 3 21412011 Continued

Facility Number: Date of Inspection: 61-T— ► 3
Waste Collection & Treatment
.4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes allo ❑ 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): L_
5. Are there any immediate threats to the integrity of any of the structures observed?
(i.e., large trees, severe erosion, seepage, etc.)
❑ Yes 5D No ❑ NA ❑ NE
6. Are there structures on -site which are not properly addressed and/or managed through a
❑ Yes
[5j 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
® 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
ONE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes 0 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): z•�/ /tt o�s- /�1C/�dS�f - —
13. Soil Type(s): 1G1J -1t --
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes Ea No ❑ 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 ® No ❑ 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 ® No ❑ NA ❑ NE
❑ Yes ZI No ❑ NA ❑ NE
19. Did the facility fail to have the 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
Uig-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.
❑ Ycs
® No
❑ NA
❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis
❑ Waste Transfers
❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V Rainfall Inspections
❑ Sludge Survey
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
No
❑ NA
❑ NE
Page 2 of 3 21412011 Continued

Facili Number: Date of Ins ection: — D13
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes ® No ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes [a No ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge? ❑ Yes ® No ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes ® No ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes ® No ❑ 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
[RNo
❑ 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 the 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
O No
❑ NA
❑ NE
33. Did the Reviewer/Inspector 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
[&No
❑ NA
❑ NE
Comments (refer to question #): 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).
Reviewer/Inspector Name:
Phone: g%33-33Do
Reviewer/Inspector Signature:
Page 3 of 3
Date: k -"; E_", -'� b4
21412011

Type of Visit: ompliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: (316utine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: ; pc7 Departure Time: County:Region: /gyp
Farm Name: &4 ia""lof � Owner Email:
Owner Name: _ &" a= / j 14- nfl ' I J, Phone:
Mailing Address:
Physical Address:
Facility Contact:/r; �; c•`.K- �',9t,v G i!l Title: Phone:
Onsite Representative: Integrator: AIV6015101rllww-
Certified Operator: Certification Number: le'y429.�
Back-up Operator:
Location of Farm:
Latitude:
Certification Number:
Longitude:
=
Swine
Degiga Cuilr i ja
Capactty r '.*Pop Wet Poultry
Design Cur er nt',
Capacity Po}�
Design Current
Cattle Capacity Pap.
Wean to Finish
Layer
Dairy Cow
Dairy, Calf
Wean to Feeder
I INon-Layer
'
Feeder to Finish
Farrow to Wean
Farrow to Feeder
D . P,oul
DesignCur�rent
Ca acityPo -
Dai Heifer
Dry Cow
Non -Dairy
Farrow to Finish
Layers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
P�'
Turkeys
_Turkey Poults
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 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 5�.No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes [—]No
[:]Yes �JNo
❑ Yes 2[ No
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Page I of 3 21412011 Continued

Facili Number: -1 Date of Inspection: r
/
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
'CS -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): 3tf
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
[M,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
(5j 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
IR No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
LKNo
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes JC No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s): /
14. Do the receiving crops differ from those 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
Eg No
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
O 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
[g No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
ES 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 2 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 3 21412011 Continued

Facility Number: - Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes allo ❑ NA ❑ NE
' 25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes [3,No ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge? ❑ Yes ® No ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification'? [:]Yes F No ❑ NA ❑ NE
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?
[:]Yes gNo ❑ NA ❑ NE
❑ Yes S No ❑ NA ❑ NE
❑ Yes [Z No ❑ NA ❑ NE
�] Yes
No
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
❑ Yes
C&No
❑ NA
❑ NE
lComments (refer to question ft Explain any YES answers and/or any additional recommendations or any other comments
ust drawings of facility to better explain situations (use additional pages as necessary).
6?n
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Phone: q/��'
Date: 6--- f 9--�d/�f/
21412011
Page 3 of 3

0
FRill Number
ty �F � Division of Water Quality ""
© 0 Division of Soil and Water Conservation S
Other Agency
Type of Visit: &Mmpliance Inspection O Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit: C>ldoutine O Complaint O Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit: Arrival Time: , © Departure Time: I It?: 3
ED County: Region: j(
Farm Name: 6E-' i q j 4c*i , '7,0&Ue_j1 rrx1ry4 Owner Email:
Owner Name: , f,,U; >- FDw r�H Phone:
Mailing Address:
Physical Address:
Facility Contact: �� { ;cx-, Title: .,o Phone:
Onsite Representative: integrator: lov 110 _
Certified Operator: �acJ Certification Number:
Back-up Operator:
Location of Farm:
Latitude:
Certification Number:
Longitude:
- -,•- -- 1 - `
DesignCurrent _
ti a
N�g Current .., Design Current
Desi n�
Cattle
$wine
Capacity*Popes 'Vet Ponitry Capacity Pop.
Capacity Pop.
inish
Cow
eeder
La er
Non -La er
Dai
Dai Calf
Finish
,S`�o
Dai Heifer
Wean
�^ Design 'Current
D Cow
FFarrowtoWean
Feeder
D . P.ouI
Ca aci Po
Non -Dairy.
Finish
La ers
Beef Stocker
Non -La ers
Beef Feeder
Pullets
Beef Brood Cow
too
Turkeys
Other
-Turkey Poults
Other
Other
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation? ❑ Yes [4 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 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
KNo
❑ 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 1 of 3 21412011 Continued

Facili Number: - Date of inspection: Zi -- / ;�L—
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes
a. If yes, is waste level into the structural freeboard? ❑ Yes
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): �3(P
5. Are there any immediate threats to the integrity of any of the structures observed?
(i.e., large trees, severe erosion, seepage, etc.)
LFLNo ❑ NA ❑ NE
[] No ❑ NA ❑ NE
Structure 6
❑ Yes [a No ❑ NA ❑ NE
6. Are there structures on -site which are not properly addressed and/or managed through a
❑ Yes
[K No
❑ NA
0 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?
[Q Yes
❑ No
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
�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
[0 Yes
[:]No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
Pq No
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes MNo ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s): "
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
[2 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
® No
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
RNo
❑ 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
[:3 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 0 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 No ❑ NA ❑ NE
23. if selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes No ❑ NA ❑ NE
Page 2 of 3 21412011 Continued

Facili Number: I Date of Inspection: -
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes ® No ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes ® No ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge? ❑ Yes 0 No ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes ER No ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document E] 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 CR 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 Reviewer/Inspector 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
®No
❑ NA
❑ NE
Comments (refer to question ff): Explain any YES answers and/orany additional recommendations or any,,Ather comments:
Use drawings of facility to better explain situations (use additional pages as necessary). :.-
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: '9- D
Date: L `v`A0/2-
21412011

Onsite Representative:
Certified Operator: Ste.
Back-up Operator:
Date of Visit: l Arrival Time: l ; p Departure Time: .'Vo j County: -.1 Region:
Farm Name: �,(fi /%� cY.r��c?�/ 7/ryt Owner Email:
Owner Name:Phone:
Mailing Address:
Physical Address:
FacilityContact: //�; �%; �, .4 a Ltlr _ 1 Title:
Integrator: MAe,, d re
Certification Number:
Phone:
Certification Number:
Location of Farm: Latitude: Longitude:
Design Current
Design ".Current
Design Current
Swine
Capacity Pop.
Wet Poultry
Capacity Pop.
Cattle Capacity Pop.
Wean to Finish
Layer ���
Dairy Cow
Wean to Feeder
Non -Layer
Dairy Calf
Feeder to Finish
Dairy Heifer
Farrow to Wean
DesignM1 Current
Dry Cow
Farrow to Feeder
� D . P,oult ,
Ca aci Po
Non -Dairy
Farrow to Finish
La ers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turkeys
Other
Turkey Poults
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 to No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes
[:]No
❑ NA
❑ NE
[] Yes
No
❑ NA
❑ NE
❑ Yes
® No
❑ NA
❑ NE
Page 1 of 3 21412011 Continued

Facility Number: - p;(� 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 1 Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier:
Spillway?:
Designed Freeboard (in): Z9
Observed Freeboard (in): 3 1
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
[S 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?
0—Yes
[Wltlo
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
[:]Yes
R] 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
[3 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 0 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): &2m 'Va(' L /17i,gz-:L-3rrZ
13. Soil Type(s):
14. Do the receiving crops differ from those desjV
ignated in the CAWMP?
15. Does the receiving crop and/or land application site need improvement?
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
the appropriate box.
❑ Yes
� No
❑ NA
❑ NE
❑ Yes
X , No
❑ NA
❑ NE
[:]Yes
[2 No
❑ NA
❑ NE
❑ Yes [4 No ❑ NA ❑ NE
❑ Yes � No ❑ NA ❑ NE
[] Yes R) No ❑ NA ❑ NE
❑ Yes ® No ❑ NA ❑ NE
❑WUP ❑Checklists ❑ Design ❑ Maps [] Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes allo
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall []Stocking ❑ Crop Yield ❑ 120 Minute Inspections [:]Monthly and 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 EZ No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 21412011 Continued

Facili Number: - Date of Ins ection: /
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes ® 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
and report mortality rates that were higher than nonnal?
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?
❑ NA ❑ NE
❑ NA ❑ NE
❑NA ❑NE
❑ NA ❑ NE
❑ Yes ® No 0 NA ❑ NE
❑ Yes [Z No ❑ NA ❑ NE
❑ Yes ® No ❑ NA ❑ NE
❑ Yes [S No ❑ NA ❑ NE
❑ Yes ® No
❑ Yes X No
[] Yes [3 No
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Comments (refer to question #): 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).
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: >
mom,
Date:
21412011

Type of Visit t�mpliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit Q)'T outine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: Arrival Time: Departure Time: i County: Region:
Farm Name: UZ a. —To To I "t, 1 t E—a rrrt - Owner Email:
Owner Name: Z4- Z22Gur--1/ _ Phone:
Mailing Address:
Physical Address:
Facility Contact: /'i1S I -i::'O I Title: Phone No:
Onsite Representative: 0 _. Integrator: r
Certified Operator: Ste-•^-�— Operator Certification Number:
Back-up Operator:
Location of Farm:
Back-up Certification Number:
Latitude: = o = I = " Longitude: = ° = 6 = "
EDesif
Swine
n Current
Capacity Population
Design
Wet PauItry Capacity
Current Design Current
Population Cattle Capacity Population
❑ Wean to Finish
La er
❑ Dairy Cow
❑ Wean to Feeder
10 Non -La er I
Dry Poultn
❑ Layers
❑ Non -Layers
❑ Dairy Calf
❑ Dairy Heifer
❑ Dry Cow
® Feeder to Finish
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Non -Dairy
❑ Beef Stocker
❑ Beef Feeder
❑ Gilts
❑ Boars
❑ Pullets
❑ Beef Brood Co
Other
❑ Other
❑ Turkeys
❑ Turkey Poults
❑ Other
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 Ufo ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
[ZNo
❑ NA
❑ NE
❑ Yes
allo
❑ NA
❑ NE
12128104 Continued

Facility Number: Date of Inspection —lo
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): / 9
Observed Freeboard (in):
5. Arc there any immediate threats to the integrity of any of the structures observed? ❑ Yes 91 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 UNo ❑ 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
T 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 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 [A No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes allo ❑ NA ❑ NE
maintenance/improvement?
11. is there evidence of incorrect application`? if yes, check the appropriate box below. ❑ Yes RNo ❑ 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)-� Oy�!r s-,✓
13. Soil type(s)
P
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
[a No
❑ NA
❑ NE
16, Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
❑ Yes
[Z No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
U No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
0 No
❑ NA
❑ NE
Comments (refer to question-#):- Explain any YES answenandfor any recommendations or any other a me'nts
,Use drawings of facility to better explain situations (use additional pages as necessary)
AL
Reviewer/Inspector Name[?- Phone: �_�63_; 33vo
Reviewer/Inspector Signature: Date:
Page 2 of 3 12128104 Continued

Facility Number:— Date of Inspection
f Required Records & Documents
19. Did the facility fail to have 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 [Z No ❑ NA ❑ NE
the appropriate box. ❑ WUP ❑ Checklists ❑ Design ❑ Maps ❑ Other
21. Does record keeping need improvement? if yes, check the appropriate box below. ❑ Yes 21No ❑ NA ❑ NE
❑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
12 No
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
ZNo
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
[3No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
(Z No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
RNo
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
J�SNo
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
JZ[No
❑ NA
❑ NE
29_
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
9No
❑ 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
JZ 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? (iel discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
[ZNo
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
51 No
❑ NA
❑ NE
A�dd�t�onahComm`enis and/oi= Drawings:° A
Page 3 of 3 12128104

Type of Visit
pFFance Inspection
0 Operation Review 0 Structure Evaluation
0 Technical Assistance
Reason for Visit
outine 0 Complaint
0 Follow up 0 Referral 0 Emergency
0 Other ❑ Denied Access
Date of Visit: Arrival Time: �� rIQ a Departure Time: County: Region:
Farm Name: 1Z1l j 1 j .x-1 / � ��iyt � Owner Email:
Owner Name: 461,' // i 4L� 2[�z11 elZ Phone:
Mailing Address:
Physical Address: p
Facility Contact: WS % Title: Phone No:
Onsite Representative: ^ :Le_ - - integrator:
Certified Operator: _S e=!& Operator CertifcNumber:
Back-up Operator:
Back-up Certification Number:
Location of Farm: Latitude: 0 0 = { = u Longitude: = ° = A =
Ig
Design current
Design Current
Design Current
Swine Capacity Population
Wet Poultry
Capacity Population
Cattle Capacity Population
❑ Wean to Finish
❑ Layer
❑ Dairy Cow
❑ Wean to Feeder
❑Nan -La er
❑ Dairy Calf
Feeder to Finish
❑ Dairy Heifer
El Farrow to Wean
Dry Poultry
❑ Dry Cow
❑ Farrow to Feeder
❑ Non -Dairy
❑ Farrow to Finish
❑ Layers
❑ Beef Stocker
❑ Gilts
❑ Non -Layers
Beef Feeder
❑ Boars
❑El
Pullets
❑ Beef Brood Co
❑ Turkeys
Other
❑ Turkey Poults
Number of Structures:
❑ Other ❑ Other
Discharees & 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?
❑ 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
IkNo
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
[ANo
❑ NA
❑ NE
other than from a discharge?
12128104
Continued

Facility Number: — I Date of Inspection a`"EDO
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
❑ Yes ,KNo ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
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
NNo
❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes
�KNo
❑ 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
9 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 alteratives that need ❑ Yes
'54No
❑ NA ❑ NE
maintenance/improvement?
11. is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes
J.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) a
13. Soil type(s) J-,"(
14_ Do the receiving crops differ from thosf designated in the CAWMP?
❑ Yes
RNo
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
KNo
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
❑ Yes
9 No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
RNo
❑ NA
❑ NE
I S. Is there a lack of properly operating waste application equipment?
❑ Yes
7❑ No
❑ NA
❑ NE
Comments (refer to question ft Explain any YES answers and/or any recommendations orrany other comments : -
Use drawings of facilit} to better explain situations. (use additional pages as necessary.) s' -=
Reviewer/Inspector Name--- 3 a_ Phone:jh
Reviewer/inspector Signature: Date:
v Z 12128104 Continued

Facility Number: Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes M-No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes IgNo ❑ NA ❑ NE
the appropriate box.
❑ WUP ❑Checklists ❑Design El Maps El other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes allo ❑ 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 9 No ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes RNo ❑ NA ❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
JR No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
C.No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
RNo
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
&L'No
❑ NA
❑ NE
Other Issues
1
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
13,No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
ONo
❑ 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
PTNo
❑ 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
PI -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
RNo
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
[E�No
❑ NA
❑ NE
Addit onal'Cgmmenti.7a dL.6 D'
I
Hv
12128104

lType of Visit VC o liance Inspection Q Operation Review Q Structure Evaluation Q Technical Assistance
ReasonforVisit Routine O Complaint Q Follow up Q Referral Q Emergency Q Other ❑Denied Access
Date of Visit: Arrival Time: r�lf Q Departure Time: County: Region:
Farm Name: W 1 Gxt�Owner Email:
Owner Name: I(L,� II i A� �iQ�l Phone:
Mailing Address:
Physical Address:
Facility Contact: Al; "A, Title:
Onsite Representative: a -—
Certified Operator:
Back-up Operator:
Location of Farm:
Phone No:
Integrator: y
Operator Certification Number: 1
Back-up Certification Number:
Latitude: 0 0= 1= u Longitude: = o= I= u
Design
Current : Design Current
Design Current
Swine
Capacity
Population �Wett�Poultry Capacity 1?opula�ttao.
C•at#le Capacity Population
❑ Wean to Finish
❑ Layer
❑ DairyCow
❑ Wean to Feeder
❑ Non -Layer
❑ DairyCalf
Feeder to Finish
(�
k _.
r, ..
❑ DairyHeifer
❑ Farrow to Wean
Dry�P�oultry
❑ D Cow
❑ Farrow to Feeder
_
❑ Non -Dairy
❑ Farrow to Finish
❑ Beef Stocker
❑ Gilts
❑ Beef Feeder
❑ Boars
?
❑ Beef Brood Co
. .
Other ..
F
Number Structures:
❑ Other
_
of
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ Turkey 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?
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?
Page I of 3
❑ Yes KNo ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
�-No
❑ NA
❑ NE
❑ Yes
59 No
❑ NA
❑ NE
12/28/04 Continued

Facility Number: — Date of Inspection [i`lr t7
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?:
Designed Freeboard (in):
Observed Freeboard (in): 3
❑ Yes jj�[No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes fK 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 ® 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 EgNo ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes 54No ❑ 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 q No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes JZ No ❑ NA ❑ NE
maintenance/improvement?
IL . Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes �4No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or I 0 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) �15rf`lilt.r�i[i� iou
13_ Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
[8 No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
(A No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?❑ Yes
93 No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
tZ No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
J-No
❑ NA
❑ NE
C.. �eE��C ' x .]saga✓ _ a�a'+� _ - �t w -�J#
omme(refer to;questaon:#) Egplainany YE$; answers�and/oratiy recommeedati on or any other comments'
�Use"drawptgs offacdity�to�better ezPlaan situation`s," {use addrtional,pages�as�necessary)
-,��R'J �''d"•r .— � «..mc ,;. «ram - �".�2 b.�`4� „k.:ld�-:^_4'rLa 'j8{. iRb
ReviewerlInspector Name
Phone:
Reviewer/Inspector Signature:
Date:
Page 2 of 3 112128104 Continued

Facility Number: Date of Inspection Q--
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 ® No ❑ NA ❑ NE
the appropirate box. ❑ WUP ❑ Checklists ❑ Design ❑ Maps ❑ Other
21 _ Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes R No ❑ NA ❑ NE
❑ 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?
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?
❑ Yes
No
❑ NA
❑ NE
❑ Yes
® No
❑ NA
❑ NE
❑ Yes
[,No
❑ NA
❑ NE
❑ Yes
ELNo
❑ NA
❑ NE
❑ Yes
XNo
❑ NA
❑ NE
❑ Yes
RNo
❑ NA
❑ NE
❑ Yes J4 No ❑ NA ❑ NE
❑ Yes &No ❑ NA ❑ NE
❑ Yes /fNo ❑ NA ❑ NE
❑ Yes J� No ❑ NA ❑ NE
❑ Yes
,q No
❑ NA
❑ NE
❑ Yes
Pd No
❑ NA
❑ NE
A�rldih no�al,�Coin ats�dloT:�Dr wings: �� `-
Page 3 of 3 1228104
Page 3 of 3 1228104

ivision of Water Quality S�' ��—I/
Facility Number O Division of Soil and Water Conservation
2_�M 0 Other Agency
Type of Visit (-Compliance Inspection O Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit QHCoutine O Complaint O Follow up O Referral O Emergency O Other ❑ Denied Access
Date of Visit: ®,// Arrival Time: Departures T6iime: �: Jr County: Region:
Farm Name: G'1'/1 r A-. — ?a&Jtf-& _12 Owner Email:
Owner Name .�f �/ i�i'"� �BK�� Phone:
,r
Mailing Address:
Physical Address:
Facility Contact: �/�fl�m— �4tUr'/� Title: Phone No:
Onsite Representative: ��• Integrator: ez
Certified Operator: Operator Certification Number:
Back-up Operator:
Back-up Certification Number:
Location of Farm: Latitude: = o =,
= 4{ Longitude: = ° = I =
Swine
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Boars
Other
❑ Other ^
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
FLayer
oNon-Layej
Dry Poultry
❑ Lavers
❑ Non -La ers
❑ Pullets
❑ Turke s
❑ Turke Pouets
❑ Other
Discharges & 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?
Design Current
Cattle Capacity Population
❑ Dairy Cow
❑ Dairy Calf
❑ Dairy Heifej
❑ Da Cow
❑ Non-Daty
❑ Beef Stocker
❑ Beef Feeder
❑ Beef Brood Ca
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 0 No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
El NA
El NE
El Yes
El No
❑ Yes
CqNo
❑ NA
❑ NE
❑ Yes
R No
❑ NA
❑ NE
12128104 Continued

F
Facility Number: (ost Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes �No El NA El 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): /d
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes 91 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 V] 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 ® 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/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes FX1 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 Drifl ❑ Application Outside of Area
12. Crop type(s) G!' I E2 t/-
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
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
Iallo
❑ 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):
�-► e W v % a-- � e' c eve'.- r.as /11
Reviewer/inspector Name Phone: q�33 330�
Reviewer/inspector Signature: Date: o

e
Facility Number: ,';I- — & Date of Inspection
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 Q No ❑ NA ❑ NE
the appropirate box. ❑ WUp ❑ Checklists ❑ Design El Maps ❑Other
21. Does record keeping need improvement? if yes, check the appropriate box below. ❑ Yes [R 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 ❑ Wcathcr 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
[R No
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
O No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
5? No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
P No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
® No
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
El 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
5Q 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? (iel 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
PfNo
❑ NA
❑ NE
Comments and/or Drawings:
I Z128104

/A1 `&PftS
Type of Visit 40 Compliance 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:
Departure Time: County:
so Region: FOW
Farm Name:
/
�L �! i cr.,.L
!�
1pe
Owner Email:
Owner Name:
Mailing Address: 3G 35"
Phone:
Physical Address:
Facility Contact: w /ll n , , a�w + Title: Phone No:
On site Representative: `12_,n ra, �`/� _ Integrator:
Certified Operator: �i, . �fou••. _L_a_ a+ s<� Operator Certification Number:
Back-up Operator:
Location of Farm:
Back-up Certification Number:
Latitude: Longitude:
Design Current Design Current
Swine Capacity Population Wet Poultry Capacity Population
❑ Wean to Finish
❑ Wean to Feeder
Egteeder to Finish 1 Se, 0
❑ Farrow to Wean
❑ ' Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
Other
❑ Other
❑ Layer
❑ Non -Layer
Dry Poultry
❑ Lavers
❑ 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?
Cattle
Design Current
Capacity Population
❑ Dairy Cow
❑ Dairy Calf
❑ Dairy Heifer
❑ Dry Cow
❑ Non -Dairy
❑ Beef Stocker
❑ Beef Feeder
❑ Beef Brood Cowl
i
i
t
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 5 No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
Cl Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
�N
❑ NA
❑ NE
❑ Yes
;No
❑ NA
❑ NE
12128104 Continued

Facility Number: — Date of Inspection Pal —D j
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
[j<o ❑ 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: l
Spillway?:
Designed Freeboard (in): III
Observed Freeboard (in): _ l
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
[RNo ❑ NA
❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
❑ Yes
Ej;-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
[YNo
❑ NA
❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit?
❑ Yes
L9No
❑ 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
EeNo
❑ NA
❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below.
❑ Yes
UNo
❑ NA
❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or l0 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) Prra &Awf tta n
too
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
Io
El NA
El NE
15. Does the receiving crop and/or land application site need improvement?
ElI( Yes
,U
No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination,
❑ Yes
[TNo
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
❑ NA
El NE
18. Is there a lack of properly operating waste application equipment?
El Yes
,[9,'&o
IJ No
❑ NA
❑ NE
Reviewer/Inspector Name ZV44M � �:,� Phone: p — % 5�Kt
Reviewer/inspector Signature: ,rDate:
12128104 Continued

Facility Number: FX X( Jj Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes U/No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes 9No ❑ NA ❑ NE
the appropirate box. ❑ W`Up ❑ Checklists ❑ Design El Maps El Other �,r
21. Does record keeping need improvement? If yes, check the appropriate box below. ElCIJ 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 VNo ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes IgNo ❑ NA ❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
9No
❑ NA
❑ NE
25. Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
['No
❑ NA
❑ NE
26. Did the facility fail to have an actively certified operator in charge?
❑ Yes
E�Vo
❑ NA
❑ NE
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
ElB, Yes
No
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
[Il� Yes
�y
No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
9No
❑ 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
9No
❑ 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
[(ENO
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
El Yes
,-,/
L�+1,�No
El NA
El NE
33_
Does facility require a follow-up visit by same agency?
El Yes
E No
❑ NA
❑ NE
Additionab.Comments`and]orDrawings
12128104

Type of Visit (P-C-0-mpliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit outine 0 Complaint 0 Follow up Q Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: D-`%' Arrival Time: ' b �--Departure Time: County: Region: i 0
Farm Name: w' ��!Q"+�-- �Dt1! ��� ir�� Owner Email:
Owner Name: u% %I �''�� __ ;PIP -a! e ` Phone:
Mailing Address:
Physical Address:
Facility Contact: �l //�2+r+- lOW-Lo"ll Title:
Onsite Representative: 5AP..�
Certified Operator:
Back-up Operator:
Phone No:
Integrator:
Operator Certification Number:
Back-up Certification Number:
Location of Farm: Latitude: 0 0 = 6 = u Longitude: 0 ° = f ❑ "
Design Current Design Current
Design Current
Swine
Capacity Population Wet Poultry Capacity Population
C►attle Capacity Population
❑ Wean to Finish
❑ Layer
❑ Dairy Cow
❑ Wean to Feeder
❑ Non -Layer
❑ Dairy Calf
Feeder to Finish
ry a?
�3 ��
; > ...
❑ Daia Heifer
❑ Farrow to Wean
Dry Poultry �
El Da Cow
❑ Farrow to Feeder"
'
ElNon-Dairy
El Farrow to Finish
$ ❑ Layers
El Stocker
❑ Gilts
: ❑ Non -Ls ers
ElBeef Feeder
El
❑ Boars
El Pullets
❑Beef Brood Cow
-
❑ Turkeys
Ot e
❑ Other
10 Turkey Poults
11 ❑ Other
Number o€ Structures:
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
C No
❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
❑ Yes
RNo
❑ NA
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
❑ Yes
[RNo
❑ 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
[9 No
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
RNo
❑ NA
❑ NE
other than from a discharge?
Page I 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 IB,NO ❑ NA ❑ NE
a. if yes, is waste level into the structural freeboard? ❑ Yes gt No ❑ NA ❑ NE
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in): 9'
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes
RNo
❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes
9 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
® 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
[9No
❑ 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
RNo
❑ 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) 15�t Ynrc®ldt
13. Soil type(s) P..� .
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
allo
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
R Yes
a
❑ 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
Comments (refer to question # ): Explain any YES answers and/or any recommendations or. any y othercomments.
Use-drawings;of facility to better explain situations. (use additional.pages as necessary):
Reviewer/Inspector Name 'V 011-`_ f Phone:
Reviewer/Inspector Signature: Date: 00 to
rage L oJ .3 11125/U4 uonunuea

Facility Number: (p Date of inspection/ Tb -
' Re uired Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes EgNo ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes RNo ❑ NA ❑ NE
the appropriate box. ❑ WUp ❑ Checklists ❑ Design ❑ 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 V 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
® No
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
19 No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
O No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
RNo
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
ONo
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
3No
❑ 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
®.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
KNo
❑ 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
[9 No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
JR3 No
❑ NA
❑ NE
Additional Comments andlor Drawings:
x z
Y *
H
Page 3 of 3 12128104

(Type of Visit 0 Compliance Inspection Q Operation Review Q Lagoon Evaluation
Reason for Visit 0 Routine O Complaint O Follow up 0 Emergency Notification O Other ❑ Denied Access
Date of Visit: 3I�a`1 Time: /.? : v A
Facility Number $� o2G �
Q Not QWrational Q Below Threshold
® Permitted [8 Certified © Conditionally Certified 0 Registered Date Last Operated or Above Threshold: ..
Farm Name: County:
Mailing
Name: .............................-F._................................._........................�._._...�..... Pho��nJJe No: .............. .............+........... ......... _........ ........._...
MailiII Address: � � %01">7.kL GW ' /Td rIG,I-f-�- �1�.......---.........-_
Facility Contact: .........._... Title:........_. ..... Phone No:
Onsite Representative: ----- i��• k w+ ..._._�w��i _.. _ _ _. Integrator: __/" yt2/
Certified Operator:._ L✓ 1L. ..... � s24 %f.._. ___. Operator Certification Number:__.....___
Location of Farm:
® Swine ® Poultry ❑ Cattle ❑ Horse Latitude ' 9 " Longitude • 4 "
Y _-Current
Wean to Feeder
❑Layer
:
-=
Dom'
Feeder to Finish
.2SG o
5N--
Non -Layer
0 Non -Dairy
Farrow to Wean
] ill 1�
Other
r Total Design Capacrtyt
r k
_ --TotahSSLW
Farrow to Feeder
Farrow to Finish
GiltsKF
Boars
Discharees & Stream impacts
I- Is any discharge observed from any part of the operation? ❑ Yes No
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 gal/min?
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 ❑ No
3. Were there any advetse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes ® No
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway ❑ Yes ® No
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: _. .._............ _..... - - .. _ .. - -_ ........__
Freeboard (inches): - 6
12112103 Continued

Facility Number: & E�� C Date of Inspection /3! lJ
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, ® Yes ❑ No
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or [] Yes [Q No
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 maintenancelimprovement? [I Yes JXI No
8. Does any part of the waste management system other than waste structures require maintenance/improvement? ❑ Yes ® No
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level ❑ Yes JX] No
elevation markings?
Waste Anulication
10. Are there any buffers that need maintenance/improvement? ❑ Yes J No
11. Is there evidence of over application? If yes, check the appropriate box below. ❑ Yes ® No
❑ Excessive Pond/iin�g ❑ PAN ❑`Hydraulic Overload ❑ Frozen Ground ❑ Copper and/or Zinc
12. Crop type QQ v wt..�Dcd F-� /
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)? ❑ Yes ® No
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 attor 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 ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
® Yes ❑ No
❑ Yes ® No
❑ Yes ® No
❑ Yes P No
❑ Yes P No
❑ Yes 91 No

k'aciRty.Numbers ,rz Date of Inspection
Required Records & Documents
21. Fail to have Certificate of Coverage & General Permit or other Permit readily available? ❑ Yes ® No
22. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.) ❑ Yes ® No
23. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes (N No
❑ Waste Application ❑ Freeboard ❑ Waste Analysis ❑ Soil Sampling
24. Is facility not in compliance with any applicable setback criteria in effect at the time of design? ❑ Yes ® No
25_ Did the facility fail to have a actively certified operator in charge? ❑ Yes No
26. Fail to notify regional DWQ of emergency situations as required by General Permit?
(ie/ discharge, freeboard problems, over application) ❑ Yes ® No
27. Did Reviewer/Inspector fail to discuss review/mspection with on -site representative? ❑ Yes ]j No
29. Does facility require a follow-up visit by same agency? ❑ Yes No
29, Were any additional problems noted which cause noncompliance of the Certified AWMP? ❑ Yes ZI No
NPDES Permitted Facilities
30. Is the facility covered under a NPDES Permit? (If no, skip questions 3I-35) Yes ❑ No
31. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes No
32. Did the facility fail to install and maintain a rain gauge? ❑ Yes j$ No
33. Did the facility fail to conduct an annual sludge survey? ❑ Yes ZI No
34. Did the facility fail to calibrate waste application equipment? ❑ Yes ® No
35. Does record keeping for NPDES required forms need improvement? If yes, check the appropriate box below. ❑ Yes ❑ No
❑ Stocking Form ❑ Crop Yield Form ❑ Rainfall ❑ Inspection After 1 " Rain
❑ 120 Minute Inspections ❑ Annual Certification Form
© No violations or deficiencies were noted during this visit You will receive no further correspondence about this visit.
12112103

Farm Name/Owner:
'Mailing Address: -
County: =� �w
Integrator: S,
On Site Representati
Physical Address/IA
Site Requires Immediate Attention:
Facility No. _grz — z AT -
DIVISION OF ENVIRONMENTAL MANAGEMENT
ANIMAL FEEDLOT OPERATIONS SITE VISITATION RECORD
DATE: 7- 2 7 , 1995
Time:
_J_ 4.1C
Phone:t/O
Type of Operation: Swine X Poultry Cattle
Design Capacity: ,z?SBa Number of Animals on Site: + Zs9T
DEM Certification Number: ACE DEM Certification Number: ACNEW
Latitude: Longitude: "
Circle Yes or No
Does the Animal Waste Lagoon have sufficient freeboard of 1 Foot + 25 year 24 hour storm
.(approximately 1 Foot + 7 inches) or No Actual Freeboard: t Z Ft. Inches
Was any seepage observed from the agoon s)? Yes or N&Was any erosion observed? es o To
Is adequate land available for spra No Is the cover crop adequate? Yes or o
Crop(s) being utilized:
Does the facility meet SCS minimum setback criteria? 200 Feet from Dwe in s? a or No
100 Feet from Wells? Ye r o
Is the animal waste stockpiled within 100 Feet of USGS Blue Line Stream? Yes o>,10
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 or N& If Yes, Please Explain.
Does the facility maintain adequate waste management records (vo es of manure, land applied,
spray irrigated on ific acreage with cover crop)? Yes o No /�
Additional Comments: %/�� .4,o �, �,e le �c1��4s /�I'aP�r�- 4, _ iRRira
Inspector Name
Signature
cc: Facility Assessment Unit Use Attachments if Needed.
event