850007_INSPECTIONS_20171231

for Visit: (y Routine O Complaint O Fallow -up O Referral
Other O Denied Access
Date of Visit: 'i D Arrival Time: Departure Time:® County: 54ILe5 Region: wy�
Farm Name: ITAViAOp!?_ F0.4M Owner Email: n+ tooq�-,onkitisQcr•ToM
C rQrt�U2�. IYIa� .rr, G6fri
Owner Name: 11141MOS V., Phone: J�33101 176-31 S 7 % Lt 11)
Mailing Address: 11 SS ProtfiAiP-mce Ln • , TI oe- I+.I/ , NC- a7D42-
Physical Address:
C
Facility Contact:
Onsite Representative:
Certified Operator:
Back-up Operator:
Title:
Location of Farm: Latitude:
Phone:
Integrator:
Certification Number:
Certification Number:
Longitude:
w�Hniie5 Mill P-• E 1 N wY Pamo-n+awn 12 ,/ N6405e 1 U53t115',I140in
ov L NO, 14 w 7-7 2- U P:a-rm o rt 1,
S
z �
MMCc.bDesign
Sti i
Wean to Finish
apac try
Current .
Pop.
Design
Wet Poulttr£y Capaac`ity
La er
Current Design Current
Pop. Cattle Capacity Pop.
Dai Cow
'
Wean to Feeder
1
Non -La er
Dai Calf
Feederto Finish
Farrow to Wean
..
.h
Drr P.pultr'
La ers
Design
C:a aeit +
Dai Heifer
Current D Cow
P,o iry
Beef Stocker
Farrow to Feeder
Farrow to Finish
Gilts
Non -La ers
Beef Feeder
Boars
Pullets
Turke s
Turke Poul[s
10ther
Beef Brood Cow
Other,
Other
Discharges and Stream Impacts
I. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify 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 XNo ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes []No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes :tKINo ❑NA ❑NE
❑ Yes DjrNo ❑ NA ❑ NE
Page 1 of'3 21412015 Continued

Facili Number: - • J.Date of Inspection: 0
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
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in)
,S,t�r�uc�ture II Structure 2 Structure 3
Y L�J t�
Structure 4 Structure 5
No ❑ NA ❑ NE
❑No ❑NA ❑NE
Structure 6
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes [4 No ❑ NA ❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a ❑ Yes No ❑ NA ❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWR
7. Do any of the structures need maintenance or improvement? ❑ Yes J�r&o ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes jjNo ❑ 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? r�
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes g No ❑ NA ❑ NE
maintenance or improvement? �/
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Xl Yes INo ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN> 10%or 10lbs. ❑ 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): %J
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
WNo
❑ 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
DNA
❑ NE
acres determination?
]�
17. Does the facility lack adequate acreage for land application'?
❑ Yes
YNo
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
P No
77
El NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
� No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
No
❑ NA
❑ NE
the appropriate box.
❑WUP ❑Checklists ❑Design ❑Maps ❑ Lease Agreements
❑Other:
21. Does record keeping need ' prever+tea check the appropriate box below.
Yes
❑ No
❑ NA
❑ NE
❑ Waste Application Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis
❑ Weather
Code
❑ Rainfall ❑Stocking ❑Crop Yield ❑ 120 Minute Inspections ❑ Monthly and I" Rainfall Inspections
�3lndge9prvey
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
JD�NA
❑ NE
Page 2 of 3
21V20/5 Continued

Facili Number: - 0 jDate of Inspection: l O 1-7
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes �&o ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes [—]No ;rlA ❑ NE
the appropriate box(es) below. r'
❑ Failure to complete annual sludge survey ❑ Failure to develop a PDA 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
❑ NA
❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
❑ Yes �lo
❑ NA
[3 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 �] 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 XNo
❑ 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?
Oyes
❑ 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 an
other comments.
Use drawings of facility to better explain situations (use additional pages as necessary).
S oil }es f l ake. Z 616 . mo u e- 6�_ 0o n 'i V1 � 14
I" fain eheal_s ? Caol�,ao s)
F�eeboo�-d re coudeck t,Dee,l l ? I "mate -Its -- -�dt west
t;21� L'a.lilora-ltioh Pe,��rm�d in ao►Saz.aol�?�,Q,�..�.O�w�`1/t(�,Or�
3y Animals were la-5� A6j wi tl 6o—
rl5tde.re,c� aband.oln�d �� Need Io% -km S{�ot,-��o..Glli� ivy vs�o
TOINk. Shot, 5 homey wt�ovlu3/ btr6A4\er-, Mtju I�5hpw o
l
�`'3�Iz�aol� wa�t� � o.oz I�s.N�ItxA
15. Need peon-kLrol broad lee�oo��-f' weR_. 6 in 046C,°1-i0v_\ �'-ie�A�'or�hum
5tlt�� crop is nol- � ood e
3a Tow,- no � once r h 6 5 Xe s-l� vn l 0_n wa-5te-plo-Y) L D l I l n ae.A 4.1Z
No 161/1 et- h as 4AIe-
-r J�� 17 ,his
Reviewer/Inspector Name: `INN��15`JQ Pne CDC Ve, Phone: '1'1ID — qIn Q 9
Reviewer/Inspector Signature: _ I' It Date: 1 6 17
Page 3 of 3 p N L y F i g ld FS o f ,T q 3 13 �� 5 '1 VV la R 2i4 5
al. &C-0I rlS 4orT„Ae; zot7 PIIaa4;ons 4,S noPAN ba ar��e . two, l irta oh t�QS s�ttupl�.

3
.-. .._.. _...... .... ._ .... ..._.-.� Division of Water Resources. .. ..... ... .......... .. .,. .. .__........ _. _..
....... .......
❑ Division of Soil and Water Conservation
❑
Other Agency
Facility Number:
850007 Facility Status:
Active Permit: AW1850007
❑ Denied Access
Inppection Type:
Compliance Inspection
Inactive Or Closed Date:
Reason for Visit:
Routine
County: Stokes I Region:
Winston-Salem
Date of Visit:
04/11/2016 ' "EntryTime: 09:00 am
Exit Time: 10:15 am Incident k
Farm Name:
Providence Farm
Owner Email:
�
Owner:
Thomas K Shore Jr
Phone:
36-427-9804
Mailing Address:
1155 Providence Ln
Pine Hall NC 270428130
Physical Address:
Facility Status: ❑ Compliant Not Compliant Integrator:
Location of Farm: Latitude: 36" 21' 20" Longitude: 80° 04' 15"
From WSRO - US 311 North to Hwy 772. Turn left onto 772. Go 1 and 1/4 miles to owner's mail box (with name on top). Turn left
directly across road from the mailbox onto private lane and continue to end of the lane.
Question Areas:
Dischrge & Stream Impacts Waste Col, Star, & Treat Waste Application
Records and Documents Other Issues
Certified Operator: Thomas K Shore Operator Certification Number: 21439
Secondary OIC(s):
On -Site Representative(s): Name Title Phone
24 hour contact name Thomas Shore Phone : [phone]
On -site representative Thomas Shore Phone : [phone]
Primary Inspector: M ,sa RPseproc�tlr. Q/Ap / Phone:
Inspector Signature: � . 0 A i Uproc 1 oM Date: «
Secondary Inspector(s):
JQ-f-f 1�o bi riwn
Inspection Summary:
Permit renewal due 6/30/2018: OIC was updated 10114/2015, due again 10/14/2016.
21.) May 2015 applications on Sorghum and fescue ok.
21.) Soil test dated 3/28/2016. Soil test not performed in 2015 as required.
30.) Did not contact WSRO when waste level went above maximum (bottom mark). wasletgoes:8bgv0_mazimum'.
ehLttompipe . ML1S:,r ord (reel2,oardlle.. IURekly,(See 2013/2015 reports)
21.) Need to�iitaPthattfie wastesystem is checkediaRer each'rainfall event exceedingltjnchq
Left summary of items that MUST be included in records next year. Need to add 1 inch rainfall.checks of system. mmr
page: 1

0
Permit: AWI850007 Owner - Facility: Thomas K Shore Jr Facility Number: 850007
- Inspection Date:. 041.11116 - ..-lnpsection Type: Compliance Inspection ---. Reason -for Visit: -Routine ... .......... . _.........,....
Waste Structures
Disignated Observed
Type Identifier Closed Date Start Date Freeboard Freeboard
Waste Pond WASTE POND 54.00
1
page: 2
r

Permit: AW1850007 Owner - Facility : Thomas K Shore Jr Facility Number: 850007
... - - - Inspection Dater -04111/16 .... Inpsection Type: Compliance Inspection .. Reason for Visit: -Routine - -
Discharges & Stream Impacts
Yes
No Na No
1. Is any discharge observed from any part of the operation?
❑
0 ❑
❑
Discharge originated at:
Structure
❑
Application Field
❑
Other
❑
a. Was conveyance man-made?
❑
❑ M
❑
b. Did discharge reach Waters of the State? (if yes, notify DWQ)
❑
❑ 0
❑
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)
❑
❑ 0
❑
2. Is there evidence of a past discharge from any part of the operation?
❑
0 ❑
❑
3. Were there any observable adverse impacts or potential adverse impacts to Waters of the
❑
0 ❑
❑
State other than from a discharge?
Waste Collection, Storage & Treatment
Yes
No Na No
4. Is storage rapacity less than adequate?
❑
0 ❑
❑
If yes, is waste level into structural freeboard?
❑
5. Are there any immediate threats to the integrity of any of the structures observed (I.e./ large
❑0
❑
❑
trees, severe erosion, seepage, etc.)?
6. Are there structures on -site that are not properly addressed and/or managed through a
❑
0 ❑
❑
waste management or closure plan?
7. Do any of the structures need maintenance or improvement?
❑
0 ❑
❑
B. Do any of the structures lack adequate markers as required by the permit? (Not applicable
❑
0 ❑
❑
to roofed pits, dry stacks and/or wet stacks)
9..Does any part of the waste management system other than the waste structures require
❑
M ❑
❑
maintenance or improvement?
Waste Application
yea
No Na No
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑
❑
❑
maintenance or improvement?
11. Is there evidence of incorrect application?
❑
M ❑
❑
If yes, check the appropriate box below.
Excessive Ponding?
❑
Hydraulic Overload?
❑
Frozen Ground?
❑
Heavy metals (Cu, Zn, etc)?
❑
PAN?
❑
Is PAN > 10%/10 lbs.?
❑
Total Phosphorus?
❑
Failure to incorporate manure/sludge into bare soil?
❑
Outside of acceptable crop window?
❑
Evidence of wind drift?
❑
Application outside of application area?
❑
page: 3

• 0
�.
Permit: AWI850007 Owner - Facility : Thomas K Shore Jr Facility Number:
850007
-- - - - - Inspection Date: • 04/11/16 ..._ Inpsection Type: Compliance Inspection Reason for Visit:
- Routine - -
-. - -
Waste Application
Yea No No No
Crop Type 1
Fescue (Pasture)
Crop Type 2
Sorghum,
Sudex (Pasture)
Crop Type 3
Crop Type 4
Crop Type 5
Crop Type 6
Soil Type 1
Soil Type,!
Soil Type 3
Soil Type 4
Soil Type 5
Soil Type 6
14. Do the receiving crops differ from those designated in the Certified Animal Waste
❑
❑
❑
Management Plan(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 acre
❑
❑ 0
❑
determination?
17. Does the facility lack adequate acreage for land application?
❑
0 ❑
❑
18. Is there a lack of properly operating waste application equipment?
❑
M ❑
❑
Records and Documents
Yes
No Na No
19. Did the facility fail to have Certificate of Coverage and Permit readily available?
❑
M ❑
❑
20, Does the facility fail to have all components of the CAWMP readily available?
❑
❑
❑
If yes, check the appropriate box below.
WUP?
❑
Checklists?
❑
Design?
❑
Maps?
❑
Lease Agreements?
❑
Other?
❑
If Other, please specify
21. Does record keeping need improvement?
0
❑ ❑
❑
If yes, check the appropriate box below.
Waste Application?
❑
Weekly Freeboard?
0
Waste Analysis?
❑
Soil analysis?
Waste Transfers?,
❑
Weather code?
❑
Rainfall?
❑
Stocking?
❑
page: 4

Permit: AW1850007 Owner - Facility : Thomas K Shore Jr Facility Number: 850007
. - - . Inspection Date: .04111/16 •.- -. Inpsection Type: Compliance Inspection ...... Reason for Visit: Routine . .... -.
Records and Documents
Yea No Na No
Crop yields?
❑
120 Minute inspections? -
❑
Monthly and 1" Rainfall Inspections
Sludge Survey
❑
22. Did the facility fail to install and maintain a rain gauge?
❑
0 ❑
❑
23. If selected, did the facility fail to install and maintain a rainbreaker on irrigation equipment
❑
❑ E
❑
(NPDES only)?
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑
E ❑
❑
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check the
❑
❑ 0
❑
appropriate box(es) below:
Failure to complete annual sludge survey
❑
Failure to develop a PDA 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?
❑
0 ❑
❑
27. Did the facility fail to secure a phosphorous loss assessment (PLAT) certification?
❑
0 ❑
❑
Other Issues
Yea No Na No
28. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑
110
❑
and report mortality rates that exceed normal rates? .
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 regional DWQ of emergency situations as required by Permit?
0
❑ ❑
❑
(i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility?
❑
❑ 0
❑
If yes, check the appropriate box below.
Application Field
❑
Lagoon / Storage Pond
❑
Other
❑
If Other, please specify
32. Were any additional problems noted which cause non-compliance of the Permit or
❑
E ❑
❑
CAWMP?
33. Did the Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑
0 ❑
❑
34. Does the facility require a follow-up visit by same agency?
❑
E ❑
❑
page: 5

O!i__ l,_�l
(Type of Visit: ) Colitpliance Inspection U Operation Review O Structure Evaluation Q Technical Assistance I
Reason Lor Visit: Routine Q Complaint Q Follow-up Q Referral Q Emergency Q Other 0 Denied Access
Date of Visit: 4 tt l6 Arrival Time:
Time: ; County: KE Region: L%I'S
Farm Name: PUMM&W-.E FAUA Owner Email: S GNbRE 00 a tP� TR.-AO.R(Z.Cpnn
Owner Name: jNk6A►d K. SNoRE Phone: (SU) al?0 •315i
Mailing Address: 116-5 P (t0V n 6MC-6 U-3 t P W B *-LL � AIL 270 41
Physical Address:
Facility Contact: TF(OMhS K sKb(t,E Title:
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Phone:
Integrator:
Certification Number:
Certification Number:
Longitude:
US axtV3 lac kkta -77a , t X.1Sni O PR0Vkl36++C6 W
Us. MtU. -m W►J ito., ►J S L
Swine
Wean to Finish
Design
Capacity
Current
Pop.
Design Current
Wet Poultry Capacity Pop.
La er
Design Current
Cattle Capacity Pop.
Dai Cow \ p
Wean to Feeder
Non -La er
Dai Calf
Feeder to Finish
Farrow to Wean
Design Current
I)r,+ Unit q Ca achy P,o P.
Layers
Dai Heifer
D Cow
Non-Dai r
Beef Stocker
Farrow to Feeder
Farrow to Finish
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Other
Other
Turke s
Turke Poults
Other
M
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 WNo ❑ NA ❑ NE
[-]Yes [:]No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes o
❑ Ye gNo
❑ NA ❑ NE
❑ NA ❑_NE
❑ NA ❑ NE
❑ NA ❑ NE
❑NA ❑NE
Page 1 of 3 21412014 Continued

Facili Number: - • Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes No ❑ NA ❑ NE
a. If yes, is waste level into the structural Freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structure Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier. +
�..6
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): S
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes Io ❑ NA
❑ NE
(i.e., large trees, severe erosion, seepage, etc.) .`T/
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? JJJ"^""^��t
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 KNo ❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes JX<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 KNo ❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes No A
❑ NE
maintenance or improvement?
I I . Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes 5Io ❑ NA
❑ NE
❑ Excessive Pending ❑ 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?
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.
❑ WUP ❑Checklist ❑ Des' n ❑ M ❑ L A t
❑ Yes
C No
❑ NA
❑ NE
❑ Yes
x10
❑ NA
❑ NE
❑ Yes
No
ANA
❑ NE
❑ Yes
,❑_/
IYI No
❑ NA
❑ NE
❑ Yes
1j _,Wo
77�
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
❑ Yes
VNo
❑ NA
❑ NE
❑Oth
s g aps ease greemen s er.
= need ' yes, check the appropriate box below. X, Yes ❑ No ❑ NA ❑ NE
&20
WeWaste AnalysisWeather Code
ARainfall Stocking Crop Yield ❑ 120 Minute Inspections ❑ on[ y 1" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes IN No ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes !!!"❑"""' No )rA ❑ NE
Page 2 of 3 21412014 Continued

Facility Number: q Date of [ns ection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? MW
❑ Yes
dNo
❑ NA
❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check
❑ Yes
[:]No
JXNA
❑ 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
14, 3D ) 6
List structure(s) and date of first survey indicating non-compliance:
^�
IJ�I
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
P(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:
❑ Yes
[:]No
*A
❑ NE
[:]Yes
WNo
❑ NA
❑ NE
Aryes
❑ No
❑ NA
❑ NE
[:]Yes
❑ No
VNA
❑ NE
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? Z"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 XNo ❑ NA ❑ NE
Comments (refer to question #): Explain any YES answers and/or anyaddidonal recommendations or any other comments.
Use drawings of facility to better explain situations (use additional pages as necessary).
?GMr ' Imme srtt_ 0u6 *01 l8
i
r
^'/brit%t � � � •
o ,oa-- ll�s A N/iZ6
Reviewer/Inspector Name:
1
M
Phone: 1616 —
6f
Reviewer/Inspector Signature:
Page 3 of 3
Date:
2 417014

for Visit: (I Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: I Departure Time: Q 1 County: I�rt- 5 Region: W 5 RQ
Farm Name: NQU� LCe_ EarM Owner Email: ( ,57 lOex)Z@,*I J f-r.
Owner Name: l 6 &Ad15 L1_ - . 5 ko 6r-4.• Phone: 63(0) q -7 6 — 3 16- % ('.P'm
Mailing Address:
Physical Address:
Facility Contact: —ffAONL 5 kor1L_ Title:
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Phone:
Integrator:—�
Certification Number: /
Certification Number:
Longitude:
U 5 36I N , N et w y ?l z 4
W. ones A611 j E N w 'FZAerwaahnn
IN IM.i Is-S
9d,
Pro vt d eat ce Lo-n e
J15 311 5AW1%N er
Design Current
Design
Current
Design Current
Swine
Capacity Pop.
Wet Poultry
Capacity
Pop.
Cattle
Capacity Pop.
Wean to Finish
La er
Dai Cow
Wean to Feeder
]Non -Layer
Dai Calf
Feeder to Finish
DairyHeifer
Farrow to Wean
Design
Current
D Cow
Farrow to Feeder
Dr, P,oultr.
Ca aci
P,o P.
Non -Dairy
Farrow to Finish
La ers
Beef Stocker
Gilts
Non -La ers
Beef Feeder
Beef Brood Cow
Boars
Pullets
Turke s
Other
Turke Points
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?
Page 1 of 3
1'
❑ Yes ONo ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes [-]No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
[-]Yes ❑ NA ❑ NE
[:]Yes VNo ❑ NA ❑ NE
21412014 Continued

Ank
Facility Number: Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes �2No ❑ 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: j/JOmp— POINq
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes [XrNo ❑ 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 ZNo ❑ 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 0 No ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes XrNo ❑ 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 ZNo ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes No ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes �No ❑ NA ❑ NE
❑ Excessive Pending ❑ 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 ❑'Evideence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s): '/Ll/� � G�C� i� l� D
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes t?<o ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes Da'NIo ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes ❑ No �NA ❑ NE
acres determination? lll"''
17. Does the facility lack adequate acreage for land application? ❑ Yes W No ❑ NA ❑ NE
18. Is there a lack of properly operating waste application equipment? ❑ Yes J[�No ❑ NA ❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes J�No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes �No ❑ NA ❑ NE
the appropriate box.
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. es record keeping neFekly
vement? tfyes eheel rbeiew. es ❑ No ❑ NA ❑ NE
YWa Applicat' n Freeboard Waste Analysis oil Analysis �s ❑ Weather Code
Rainfall lockingYield 0 Minute Inspections onthly and 1" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? []Yes Z No ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes ❑ No 1 4A ❑ NE
Page 2 of 3 21412014 Continued

FacilityNumber: - • 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 I �,NA ❑ NE
the appropriate box(es) below.
TT
❑ 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
❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
❑ Yes
',Q'No
❑ No 5(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
I�f No ❑ NA ❑ NE
If yes, contact a regional Air Quality representative immediately.
77``''''
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
❑ Yes
eNo ❑ 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 p<o
❑ NA
❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes C�rNo
❑ NA
❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes ONo
❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes CS No
❑ NA
❑ NE
(Comments (refer to question#): Explain any YES answers;and/orany additional recommendations or any other comments.
Use drawiaps of facility to better explain situations (use additional Mazes as necessarv).
lad S+A-LQ 044 cxLA.4 -Lo(9,cYI Tif;lC:tS recP.liv W0.Si-e-
V
10
Groff �i�ld mn So Urv) `I�►�5 �er�v�
_711s115-= O, 36
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
41x A& W)
Phone: .I 16 - 96 q 9
Date: 1 02 4
21412014

Type of Visit: Compliance Inspection 0 Operation Review Q Structure Evaluation O Technical Assistance
Reason for Visit: ORoutine O Complaint 0 Follow-up 0 Referral O Emergency O Other O Denied Access
Date of Visit: Arrival Time: Departure Time: County: JI Ot eS Region: (.a SFs
Farm Name: P I'O V I; (� ,Gr+ C e.. Far wt Owner Email:
Owner Name:
Mailing Address:
Physical Address: W
Facility Contact: 11p m S Vl O r-e— Title: Phone:
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Integrator:
Certification Number:
Certification Number:
Latitude: Longitude:
US nwy! It N I I w
1/ y � V1It L,641,0—
-77a.4,+ur
o
%
14
wiIley
Swine
Wean to Finish
Design Current
Capacity Pop.
Wet Poultry
La er
Non -La er
Design
Capacity
Current
Pop.
Cattle
ai Cow
DairyCalf
Design
Capacity
Current
Pop.
Wean to Feeder
Feeder to Finish
DairyHeifer
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Dr P,oultr.
Layers
Design
Ca acl
Current
P,o
D Cow
Non -Dairy
Beef Stocker
Gilts
Non -Layers
NJ
Beef Feeder
Boars
Pullets
JBeefBroodCow
Other
Other I
I
Turkeys
Turkey Pouets
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 E] No ❑ NA ❑ NE
[:]Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
XNo
❑ NA
❑ NE
❑ Yes
DR*&o
❑ NA
❑ NE
Page I of 3 21412014 Continued

Facili Number: - Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
J No
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
[-]Yes
❑ No
❑ NA
❑ NE
rp l Structure 2 Structure 3 Structure 4
Structure 5
Structure
6
`Str'uct
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
No
❑ 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
XNo
❑ 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
A 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
IyNo
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
,
I" JQ No
❑ NA
❑ NE
maintenance or improvement?
7(
11. Is there evidence of incorrect land application? If yes, check the appropriate box below.
❑ Yes
% No
❑ NA
❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals
(Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate
Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application
Outside of Approved
Area
12. Crop Type(s):
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
o
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yeso
fNo
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
j NA
❑ NE
acres determination?
TT``
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
o
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
ONo
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
[:]Yes
5,No
❑ NA
❑ NE
the appropriate box.
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements
❑Other:
21. Does record keeping need' provement?
Z Yes
[:]No
❑ NA
❑ NE
Weekly Freeboarna ysis oil Aaalysis—
fersRainfall
[39toehiti gE3-C -Ytield 120 Minute Inspections Monthly and IRainfall
!Inspectio.
22. Did the facility fail to install and maintain a rain gauge?
❑ Yes
<o
❑ NA
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
❑ No
W-KA
❑ NE
Page 2 of 3
21412014 Continued

Facili Number: I Aek I Date of Inspection:
24. Did the facility fail to calibrate waste app13L"dtion equipment as required by the permit?
❑ Yes
❑ No
�A ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check
❑ Yes
PNo
❑ 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
XNo
❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
❑ Yes
Wo
`"
❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
L�Vo
❑ 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 �'iVo
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately.
T
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
❑ Yes W'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 XNo
❑ NA
❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes XNo
❑ NA
❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes R No
❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes ANo
❑ NA
❑ NE
Comments (refer to question #)' Explain any YES answersiand/or any additional recommendations or any other comments.
Use drawings of facility to better exDlain situations fuse additional Dages as necessary).
I
I� D f'►"�` �` "' 144h
#So gkne5
Reviewer/Inspector Name:
12d0`-
Reviewer/Inspector Signature:
Page 3 of 3
Date: -76 — I (O
21412014

for Visit: 4 Routine O Complaint 0 Follow-up O Referral O Emergency O Other 0 Denied Access
Date of Visit: 17 %Arrival Time: Departure Time: : O[7 ounty: ,!IALP=
Farm Name: r�t]"i\/ ``A P in rp . Faris► Owner Email:
Owner Name: �0 as, I4-. s (gyp r e- I Phone{: 33&-9 7Q —3 1 S
n
Mailing Address: SS T rt) 1t' i Ae n G � t_ t 1 e 7 1 rle— hl11) , ML a 7 (]
Physical Address:
Facility Contact: Tho SkO r,0_� Title:
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Phone:
Integrator:
Certification Number:
Certification Number:
Latitude: F�� `i� tt```� Longitude:
Region: W50
li5 w\i 3/1 N. fi wy NG77 ;2—� 1, NC Hwy 77Z
Swine
Wean to Finish
Design
Capacity
Current
Pop.
Design Current
Wet Poultry Capacity Pop.
La er
IJR M�Design Current
Cattle Cfapacity Pop.
Dai Cow
Wean to Feeder
Non -La er
Dai Calf
Feeder to Finish
Dai Heifer
D Cow
Non -Doi
Beef Stocker
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Design Current
Dr, P.oultr, Ca �aci P.o
La ers
Gilts
Non -La ersI
JBcef Feeder
Boars
Pullets
Beef Brood Cow
Other
OtherI
Turkeys
Turkey Poults
10ther
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
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
No
❑ NA
❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters
❑ Yes
�] No
❑ NA
❑ NE
of the State other than from a discharge?
T—
M
Page I of 21412011 Continued

Facility Number: Date of inspection:
O
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
0� No
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
[—]No
❑ NA
❑ NE
Structure I Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier: Was+e pond
Spillway?: y S
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
[j� No
❑ NA
❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
7N
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 environmeen(tal
threat,
notify DWQ
7. Do any of the structures need maintenance or improvement?
❑ Yes
I Xl 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
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below.
❑ Yes
�[
No
❑ NA
❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge
into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application
Outside of Approved
Area
12. Crop Type(s): 4 u� 1
13. Soil Type(s): if
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
❑ No
PR�QA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
Yes
❑ No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
Yes
No F] NA
❑ NE
the appropriate box.
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements
❑Other:
21 oes record keeping geed i ement? �pwpFiete be>c kel r6 Yes [—]No
Waste Applic on Weekly Freeboar Waste Analysis Soil Analysi tee ransfets
Rainfall Stocking Crop Yield 120 Minute Inspections Monthly an 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?
Page 2 of 3
❑ Yes ❑ No
❑ NA ❑ NE
ETWeather Code
❑ NA NE
� A ❑ NE
21412011 Continued

Facili Number: - b Date of Inspection:
24. Did the facility fail to calibrate waste app�Cdtion 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 r❑� No
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a PDA 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?
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:
❑ NA ❑ NE
JI-idA ❑ NE
❑ Yes
No
❑ NA
❑ NE
❑ Yes
❑ No
NA
❑ NE
❑ Yes]
No
❑ NA
❑ NE
❑ Yes
( No
❑ NA
❑ NE
❑ Yes No ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes 7 [�J 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 [�A No ❑ NA ❑ NE
Comments (refer to question #): Explain any YES answers and/or any additional recommendations or any other comments.,:,
Use drawines of facility to better exalain situations (use additional oaees as necessarv).
• s �/ ON M.
Reviewer/Inspector Name:
Revi n pec o ' nature:
j �q Ew�ao —r �ex
-ry �
An+ Im Ytfe, D�Nja fo Md, I GoPY.
Phone: a
Date: 1112 ( A0 1 3
Co Ue_f�2T14120114. I,v u P
.2013

Type of Visit:
Compliance Inspection 0
Operation Review 0 Structure Evaluation
0 Technical 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: ® County:5 Z4E Region: 15L0
T
Farm Name: r6 v 6 eh ce Farm Owner Email: C_ j ho re. 0 a0 ZA,0 -h-I rjd . rr ,
Owner Name: �S joff\3 IL' ShDtr'P Phone: 3 3� 9 %0. J 1J�
Mailing Address: 1 1S S
Physical Address:
Facility Contact: pa ShAr� Title:
C
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Aitl , NL a70q�
Phone:
Integrator:
Certification Number:
Certification Number:
tl
Latitude: '} rpb .�. l I at7 Longitude: 6t, o q t
Design Current
Swine Capacity Pop.
Wean to Finish
Wet Poultry
La er
Design
Capacity
Current
Pop.
Cattle
DairyCow
Design Current
Capacity Pop.
12
Wean [o Feeder
Non -La er
DairyCalf
Feeder to Finish
DairyHeifer
Farrow to can
Farrow [o Feeder
Farrow to Finish
Design Current
Dr, P,pultr. Ca aci P.o P.
Layers
D Cow
Non -Dairy
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Other
Other
Turkeys
Turkey Poults
Other
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
dNo
❑ 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
No
❑ NA
❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters
❑ Yes
No
❑ NA
❑ NE
of the State other than from a discharge?
Page 1 of 21412011 Continued

I(�al�aol.�
Facili Number: • Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes XNo
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:
❑ NA '❑ NE
[XNA ❑ NE
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
rr��eevv,,''
� X No
❑ NA
❑ NE
and report mortality rates that were higher than normal?
T
29. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
XNo
❑ 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
WNo
❑ 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
>40
❑ NA
❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
�J4
❑ 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 exDlain situations (use additional Dages as necessarv).
lY �ree�S -k on &a-wt? yes. 1 st one teFi . ASAP.
2 O 11 QaTl b r a -Ai o n t, d,o e-s C J 1 bra-4o n ? u�
.1�
Logs+e l cue is o-k-
SO l
o r o? Ol �— •? (1 O 4S t"� Q FI
a tests noi-
. MvSk:
O 1 ,�
5011 fes+,5
(a.bi1 �-0.s�- �nspac�on
Reviewer/Inspector Name:
rb
) 601 51�
S U 1 o2��n
waste °`PP
V j�a/i Lao!
lbsNAMC) cya�
Phone: I I I
Reviewer/Inspector Signature.1
Page 3 of 3
Date: ( a�
For, {� 7'7 tz o
1-i1tel.vno-i -�a0

Facili Number: - (D71• Date of Inspection:
b
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
[:]Yes
gNo
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No
❑ NA
❑ NE
Structure I Structure 2 Structure 3 Structure 4
P6
Structure 5
Structure 6
Identifier: OL'5
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
y /
[No
❑ NA
❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
T'
6. Are there structures on -site which are not properly addressed and/or managed through a
❑ Yes
XNo
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health
or environmental threat,
notify DWQ
7. Do any of the structures need maintenance or improvement?
Yes
[]No
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
0�`No
❑ NA
❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require
❑ Yes
ONo
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes 2(No ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes ❑ No ❑ NA PNE
❑ 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): Fe- S U 2-, V1
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
XN0
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
XNo
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
❑ No
�tNA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
I R No
`7XNo
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? Ej7C �
rYes
YY❑
❑ No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
Yes
No
❑ NA
❑ NE
the appropriate box.
T'
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements
❑Other.
a eeping need itex be
Yes
❑ No
❑ NA
❑ NE
pplication Weekly Freeboard Was Soil alyis
G
�anafers—
❑ Weather
Code
❑Stocking Crop Yield ❑ 120 Minute Inspections ❑Monthly and 1" Rainfall Inspections
22. Did the faci rty ail to install and maintain a rain gauge?
Pd Yes
❑ No
❑ NA
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
[:]No
19NA
❑ NE
Page 2 of 3
21412011 Continued

Type of Visit: T Compliance Inspection Q Operation Review Q Structure Evaluation O Technical Assistance
Reason for Visit: (Routine Q Complaint 0 Follow-up Q Referral Q Emergency O Other Q Denied Access
Date of Visit: Z 1 Arrival Time: Departure Time: County: Region: l.�L
Farm Name: ?My IAWC'P _ Fxr!4 Owner Email: n
Owner Name: ��nL)a 5 V, 5 ho r t Phone: [phone] , 31.5 -/-�t
Mailing Address: P"rouidenc e_ L&n e
A
Physical Address: a yve�
Facility Contact: �T}- S j10 f'C, Title:
OnsiteRepresentative: xQr 1
Certified Operator: r',Q,n �' 4-lT�� S t1 O t-t✓
Back-up Operator:
Location of Farm:
Phone:
tntegratar^ k eA+ — n W l hrs .
y c.
Certification Number:
Certification Number:
�
Latitude: U Longitude: SD 04 15
US 3 l 1 N3. fo it Lo %a L or7to 7-2.
Design Current
Swine Capacity Pop.
Wean to Finish
Design Current Design Current
Wet Poultry Capacity Pop. Cattle Capacity Pop.
ILayer I bairyCow
Wean to Feeder
Non -La er I I
Dairy Calf
Feeder to Finish
Dairy Heifer
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Design Current Dry Cow
Dn' P,oultn+ C•a aeI Pao , Non-Dai
Layers Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Other
Other
Turkeys
Turkey Puuets
Other
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
eNo
❑ 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
bl No
❑ NA
❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters
❑ Yes
o
❑ NA
❑ NE
of the State other than from a discharge?
T
Page 1 of 21412011 Continued

Facili Number: - 0 % • Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
Yes [—]No
9
❑ 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:�Oh�
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
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 �dNo
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify 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 I v No ❑ NA ❑ NE
maintenance or improvement?
Waste Application �/
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes I IL No ❑ NA ❑ NE
maintenance or improvement? `Y'
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes Nallo ❑ 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): (�tQYQq 1-/,qQ, a�`_ y _ t-e-S"e FQstu ff—
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 XNo ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable []Yes ❑ No ONA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application? ❑ Yes Wo ❑ NA ❑ NE
18. Is there a lack of properly operating waste application equipment? ❑ Yes I XI No ❑ NA ❑ NE
Required Records & Documents TT
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes No ❑ NA ❑ NE
the appropriate box.
❑WUP ❑Checklists ❑Design []Maps [:]Lease Agreements ❑Other.
W21. oes record keeping need i rovemenO Ifyesre ' trbex be ❑Yes No ❑ N ❑ NE
Raste Applica 'on eekly Freeboard Waste Analysis oil Analysis [ �✓eather Code
ainfall Stocking [Crop Yield mute nspec onthly and l" Rainfall Inspections DSk+ 4"wwey-
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes 116 No ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes ❑ No ,WA ❑ NE
Page 2 of 3 21412011 Continued

Facility Number: Date of Inspection: o/
24. Did the facility fail to calibrate waste app ion 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 ,JR: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?
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:
❑ Yes r� No
❑ Yes ❑ No
❑ NA ❑ NE
1;�,idA ❑ NE
❑ Yes 0 No ❑ NA ❑ NE
❑ Yes Q� No ❑ NA ❑ NE
❑ Yes �9No ❑ NA ❑ NE
❑ Yes � )(l No ❑ NA ❑ NE
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 #): 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).
. ¢q eAm ► on on e wAo `_n 1e_m e_v)i- ? CTI2E675 /) &
ns IN cr= aolo ? Apri l ao tt also..
F�pp li c,a-1i o
��MusttTpl4
A50— w1i n 30 cl t�s
�usi- &akt bro-t-e W/jh
30 cka,s
whenas+ e o
on►�-r %.� �.6-tu t� o-� � �o t (.
�/ d0tj = 0. q 3 146. N /1600 goA
Reviewer/Inspector Name:
Phone: 11 I —SaZ 8 9
Reviewer/Inspector Signature:
Page 3 of 3
Date: 121 I 9 1—L
21412011

Type of Visit Xcompliance Inspection O Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit Routine 0 Complaint O Follow up O Referral O Emergency O Other ❑ Denied Access
'
Date of Visit: di 7-)0 1Arrival Time: LrJ Departure Time: County: R eS Region:
Farm Name: F10yICIP.NL'6 5r-M Owner Email: Kel�SkarC sly-M) 1 iye-, e0m
l�
Owner Name: T �'lorv\GS T�, Shore Phone: 336"970-315
7
Mailing Address: I 1 SS rpIbviLleyycp L-4hE p'" ' PA I I , �j G 2.7Q 2-
Physical Address: JCiMC
,J� C f s- 991/
Facility Contact: �en7 Jhofe Title: Phone No.Q_1f03- 371910
Onsite Representative: dn� Integrator:
''//
!t. � Wf y
Certified Operator: erl4- �/Glg t5'tarP- Operator Certification Number:
Back-up Operator:
Location of Farm:
Back-up Certification Number:
Latitude: �o 2� ® Longitude: $0 0 ®. 0
US 14wy 31 tJ, ,flwy'772,a C,1-6 '772.
-
Design Current
Design Current
Design Current
Swine Capacity Population
Wet Poultry Capacity Population
Cattle CacityAllijoulation
❑ Wean to Finish
10 Layer I
ErDairyCow I2 O 0
❑ Wean to Feeder
JO Non -Layer 1
0 Dairy Calf
❑ Feeder to Finish
❑ Dairy Heifer
❑ Farrow to Wean
Dry Poultry
❑ Dry Cow
❑ Farrow to Feeder
❑ Non -Dairy
❑ Farrow to Finish
❑ Layers
❑ Beef Stocker
❑ Gilts
❑ Non -Layers
❑Beef Feeder
❑ Boars
❑ Pullets
❑ Beef Brood Cow
❑ Turkeys
Other
1110 Other
Number of Structures:
❑ Turk e Poults
1.0 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)
e. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
Page I of 3
❑Yes�No ❑NA ONE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No
❑ NA ❑ NE
❑ Yes XNo
❑ NA ❑ NE
❑ Yes Qp No
❑ NA ❑ NE
12128104
Continued

Facility Number: $ Q • Date of Inspection Z / •
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Structure I _ Structure 2 Structure 3 Structure 4
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
through a waste management or closure plan?
❑ YesgNo El NA ❑ NE
❑ Yes
«<<<<❑\\\\\\No ❑ NA ❑ NE
Structure 5 Structure 6
❑ Yes XNo ❑ NA ❑ NE
❑ Yes)KNo ❑ NA ❑ NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? XYes ❑ No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes XNo ❑ 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 pvo ❑ NA ❑ NE
maintenance or improvement? /
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes 'X___`No ❑ NA ❑ NE
maintenance/improvement? �,/
11. Is there evidence of incorrect application? If yes, check the appropriate box below. El Yes XNo El NA ❑ NE
El Excessive Ponding ❑ Hydraulic Overload El Frozen Ground El 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)
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes 'gNo
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes XNo
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?
❑ Yes ❑ No9NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes �No
❑ NA
❑ NE
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).
1 q irt ,
'1�I ✓h �Ia_n�CMEm {`',i��I M¢ f +�r,,41.,� ��eeb&(e�Q gp,pl� 1D-0hS�dzai
octs� W Sn mv-0 fV A'10, I1NG1 i 1 I bf �f
0l }o "V'Pl� spec►• braij Ja it
Reviewer/InspectorName i J'i' b .,P.` wMi .st s;t,"t'w qtr3'�SI3{t,(��l'. Phone: r% 71— fZ-
Reviewer/Inspector Signature. Q / f� A / t(r j& � Date: OS /Z-- O
Page 2 of 3

Facility Number: 8✓`— D'7 *of Inspection OS I z 0 •
Reauired Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑'Yes XNo ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes�No ❑ NA ❑ NE
the appropriate box. ❑ WUP ❑ Checklists ❑ Design El Maps ❑OtherWtL\wa '^,,,,'�
21. Does record keeping need improvement. Yes ❑ No El NA ❑NE
/ �'' o1e� NPD65 o(NI
R Wate Application E Weekl .Freeboar Q Waste Analysi Soil Analysis
0 Rainfall 01stocking Crop Yield -fJ-t20 Minute Inspections [ja onthly and V Rain Inspection ther Code
22. Did the facility fail to install and maintain a rain gauge? ICI Yes ❑ No ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes ❑ No >?�QA ❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes *o
❑ 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 *R�(No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes ❑ No
0 NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes -No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes XNo
❑ 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 KNo
❑ 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 XNo
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
,,�/
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
�Q Yes ❑No
❑ NA
El NE
33.
Does facility require a follow-up visit by same agency?
❑`Yes I2/�No
❑ NA
❑ NE
2-Z v� 1313 Pfevfat��y y%z7) 4N
.1d IS A T° WIaQ ? o+ 1A-e
- �ara Soil ln,r a.//� A/16,L/e7`�T ONNq a ? Nol �e �I .'Lj A54,
N
U ` N8ii1 raf Say., �eJ ? An�lysi� �
W41i<
O&IL 1-.:0J4 OAot�oL2o,M��tcl�,�s..
b
2`f Cqf; d N
32, L_e4+ 61i ° ^r
Page 3 of 3 12128104

Incident Report
��oFwarFROG
P Report Number:
201001647 NOV-P10 pl
Incident Type: Non -Compliance Reporting
On -Site Contact:
Category: APS - Animal
First/Mid/Last Name:
tncitlentStarted:11/12/2009
Company Name:
County: Stokes
Phone:
City:
Pager/Mobile Phone: /
Farm #: 085-0007
Responsible Party:
Reported By:
Owner:
First/Mid/Last Name:
(—PermiP."I AWI850007
Company Name:
Facility: Providence Farm
Address:
First Name: Thomas
Middle Name: K
City/State/Zip:
Last Name: Shore
Phone:
Address 1155 Providence Ln
Pager/Mobile Phone:
City/State/Zip: Pine Hall INC 2704281
Phone:
Material Category: Estimated Qty: UOM
DD:MM:SS Decimal
Latitude:
Longitude:
Location of Incident: PRovidence Lane
Address:
City/State/Zip
Chemical Name Reportable Qty. lbs. Reportable Qty. kgs.
Position Method:
Position Accuracy:
Position Datum:
Report Created 05/14/10 01:20 PM Page I

0 0
Cause/Observation:
Action Taken:
Incident Questions:
Did the Material reach the Surface Water? Unknown
Surface Water Name?
Did the Spill result in a Fish Kill? Unknown
If the Spill was from a storage tank indicate type.
Containment? Unknown
Cleanup Complete? Unknown
Directions:
Comments:
Water Supply Wells within 1500f1: Unknown
Access to Farm Animal Population
Structure Questions
Conveyance:
Estimated Number offish?
(Above Ground or Under Ground)
Groundwater Impacted : Unknown
Spray Availability
Report Created 05/14/10 01:20 PM Page 2

Access to Farm
Farm accessible from the main road?
Animal Population
Confined?
Depop?
Feed Available?
Mortality?
Spray Availability
Pumping equipment?
Available Fields?
Structure Questions
Breached?
Inundated?
Overtopped?
Water on outside wall?
Poor dike conditions?
Waste Structure Type Waste Structure Identi inches
Waste Pond WASTE POND 18.00
Event Type
Incident closed
Requested Additional Information
Report Received
Referred to Regional Office - Primary Contact
Report Entered
Incident Start
Event Date
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Plan Due Date Plan Recieved Date Level OK Date
2010-05.11 11:52:43
2009-11-12 08:00:00
Due Date Comment
Report Created 05/14/10 01:20 PM Page 3

• �....
Standard Agencies Notified:
Agency Name Phone First Name M.I. Last Name Contact Date
Other Agencies Notified
Agency Name Phone First Name M.I. I Last Name Contact Date
DWQ Information
Report Taken By:
Report Entered By: Regional Contact:
Melissa Rosebrock
Phone:
Date/Time:
2010-05-11 11:52:43 AM
Referred Via:
Did DWQ request an additional written report?
If yes, What additional information is needed?
Report Created 05/14/10 01:20 PM Page 4

I Facility Number I'JS H D� 11
Division of Water Quality
Division of Soil and Water
Other Agency
1d-PAl
Type of Visit
Pompliance Inspection
0 Operation Review O Structure Evaluation
0 Technical Assistance
Reason for Visit
0 Routine 0 Complaint
0 Follow up Q Referral 0 Emergency
0 Other ❑ Denied Access
Date of Visit: j Arrival Time:= Departure Time: l ► /J f County: 6+0V----5 Region: LA35 P—b
Farm Name: t f O lft &Mce- Fot�-m `�11T�UOww'n'er Eu ail: ��rt+ pregf(� C It • tAfl
Owner Name: tQA W Q j �ti • �hOY L t St' Phone: 33in • 4 76. 3
Mailing Address:
Physical Address:
Facility Contact: . - . use:
Onsite Representative: V\ V'ks f'P_
Certified Operator: �� ��� �� � Sj'n"
Back-up Operator:
Location of Farm:
US wwy
Swine
Other
❑ Other
rnone ivu:
Integrator:
rS
Operator Certification Number: 0- f 31 ! a O 10
Back-up Certification Number:
Latitude: I 9 EA' 5a" Longitude:
311 N -i-o l^� y 11.Z. Le-C+ ovy4o 7 Z t
Design Current Design Current
Capacity
�Population
l Wet Poultry Capacity Population
I I ❑ Layer
❑ Non -La et
Dry Poultry
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
ownawr lim
Design Current
Capacity Population
Dairy Cow
Dairy Calf
❑ Dairy Heifei
❑ Dry Cow
❑ Non -Dairy
❑ Beef Stocker
❑ Beef Feeder
❑ Beef Brood Co
Number of Structures: F 7/',
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 ❑ No �NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
0
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
❑ No
NA
❑ NE
❑ Yes
❑ No
NA
❑ NE
12128104 Continued

Facility Number: 'V — 0 % • Date of Inspection ol`6
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes �No ElNA
ElNE
a. If yes, is waste level into the structural freeboard"?
❑ Yes ❑ No ❑ NA
❑ NE
Structure Structure 2 Structure 3 Structure 4
Structure 5 Structure 6
Identifier: Was _00Od _
Spillway?: V
Designed Freeboard (in):
Observed Freeboard (in):_
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes No ❑ NA
❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
'
6. Are there structures on -site which are not properly addressed and/or managed
ElYes qNo ❑ 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?
(Not applicable to roofed pits, dry stacks and/or wet stacks) El Yes �{ No [I NA ❑ NE
9. Does any part of the waste management system other than the waste structures require ❑ Yes l� No El NA El 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 0 No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN> 10%or 10lbs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window El Evidence of Wind DriDflu❑`A,pplication Outside of Area
12. Crop type(s) A .44 ,Ai� 13 A QA, 0 C _A j
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?
Yes
❑ Yes
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?❑ Yes
17. Does the facility lack adequate acreage for land application? ❑ Yes
18. Is there a lack of properly operating waste application equipment?
❑ Yes
No
El NA
❑ NE
/l
,,..r,ko
El NA
El NE
//❑''No
OkNA
❑ NE
No
❑ NA
❑ NE
No
❑ NA
❑ NE
IComments (refer to question #): Explain any YES answers and/or any recommendations or any other comments. I
Use drawings of facility to better explain sitrotions. (use additional pages as necessary):
)V2��or� ton+ro�le.d o r) QYI
IReviewer/Inspector Name f Phone: —
Reviewer/Inspector Signature. Arn. lil, ♦n �. Date:
ram- •� e — 12128104 rContinued

Facility NumOate of Inspection T_T
3
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 No ❑ NA ❑ NE
the appropriate box. ❑ WUP ❑ Checklists ❑ Design El Maps ❑Other
21. Do s record keeping need imp vement? 47=��s; [4-tl-appcepaatcb�da� El Yes �No ❑ NA ❑ NE
W to Application Weekly Freeboard, / Waste Analysis sod A lysis��.v�o ,aaef. a ❑
ainfall Eg.,stocking ❑ Crop Yield IXl 120 Minute Inspections L onthly and I" 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 [XNA ❑ NE
❑ Yes %No ❑ NA ❑ NE
❑ Yes ❑ No [(NA ❑ NE
❑ Yes gNo ❑ NA ❑ NE
❑ Yes P(No ❑ NA ❑ NE
X1 Yes o ❑ NA ❑ NE
❑ Yes � No ElNA ElNE
ElYes XNo ❑ NA ❑ NE
❑ Yes [ No ❑ NA ❑ NE
❑ Yes N(No ❑ NA ❑ NE
❑ Yes *o ❑ NA ❑ NE
Drawings:Additional Comments and/or
9-co; •.. i •
f 44
,�: . �� � � / Ili �� •I r ► /i � �i < � �'
ts
i AL�t
�� ���
1
Page 3 of 3 1 r
12128104

Dsion of Water Qualif`
Facility Number s Division o[Soil and Water Conservation
- - — 0 Other Agency. • .I
Type of Visit Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit �p Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: Qg Arrival Time: HUO04eparture Time: Fz60 ounty: JI �S_ Region: LLG A
Farm Name: em V ldenu Early) Owner Email: I CWLK00.
Owner Name: 16mxe, 1L • Shore I K) a3 . 9 10 3 1 S 7 P1
Tr • Phone: ,.
Mailing Address: 115 s- Pro \f i & e n Ce La ire n a -
Physical Address: G ame
Facility Contact: :(nnn Shores Title: Phone No:
Onsite Representative::] Ifs �0 ( P _ Integrator: kin
{ / i) !43 —37 0(p
! Certified Operator:h4)D3, aS k • , Vy `r_Q • T� Operator Certification Number:
&�Q�
Back-up Operator: e4} _r fLQ 8 71\O r P Back-up Certification Number: 1 9 b S j
Location of Farm:
to 5
US I�wy Sa N. to
DesignCurrent
❑ Wean to Finish
❑ Wean to Feeder
❑ Feeder to Finish
❑ Farrow to Wean
❑ Farrow to Feedei
n Farrow to Finish
❑ Boars
Other
Latitude:
-I a ' l
Dry Poultry
o ®•• Longitude: ® e
onto a .
-sign Current
❑ La ers
❑ 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?
0 5$3L-}e 4w y 6 h N
Cattle
Design` Current
Capacity e Population,*"
Dairy Cow
Dairy Calf
] Dairy Heifer:.
] Dry Cow
] Non -Dairy
] Beef Stocker
] Beef Feeder
] Beef Brood Cow
Number of Structures:
❑ Yes
�(No ❑ NA ❑ NE
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 1 of 3
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
0
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes [ No ❑ NA ❑ NE
❑ Yes *No ❑ NA ❑ NE
12128104 Continued

Facility Number: — • Date of Inspection0
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
Identifier. JI�asE2 �11 Structure 2 Structure 3 Structure 4
q'�O
❑ Yes *o ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):_
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
9No
❑ NA
❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
❑ Yes
QCI No
❑ NA
❑ NE
through a waste management or closure plan?
7T'
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?
X Yes
No
❑ NA
❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit?
❑ Yes
��,❑,,((
IEI No
El NA
❑ NE
(Not applicable to roofed pits, dry stacks and/or wet stacks)
77��''
9. Does any part of the waste management system other than the waste structures require
❑ Yes
O(No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
XNo
❑ NA
❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below.
❑ Yes
�(No
❑ NA
❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 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) �/d 4 0 if /W(f'l_/J LU�
13. Soil type(s) U 0
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
iSJ 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
gNo
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
ANo
❑ NA
❑ NE
Comments (refer to question 0): Explain any YES answers and/or anyxecommendations or any other comments.
Use drawings of facility to better explain situations. (use additional pages as necessary):
TA
0
Reviewer/Inspector Name
I Phone:
Reviewer/Inspector Signature:
Date:
Page 2 of 3 ` t' 12128104 Continued
Me ice. �-Osebroc Ike nc m lit) 1, n e+

Facility Number: — Q Date of Inspection $ 0
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 XNo ❑ NA ❑ NE
the appropriate box. ❑ WUP ❑ Checklists ❑ Design ❑Maps El Other
21.
Does record keeping need improvement? If yes, check the appropriate box bel .
Odyes
❑ No
❑ NA
❑ NE
❑ Waste Application ElWeekly Freeboard IV Waste Analysis oil Analysis
s e rans ers
4D-AaavaLga"i€eation
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ Monthly and I"
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
KNA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
K No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
❑ No
IXNA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
INo
❑ NA
ElNE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
ElYes
XNo
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
Yes'
❑ 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
No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
/r
31.
Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
t4No
❑ 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
X No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
XNo
❑ NA
❑ NE
tAdditional Comments and/or Drawings:
Al. cool Soil test Per�ormed?�J l COU(� 2oUg �O(t✓13��S�iS.
A4. None4wcL on Bali bra}ed?UJ1t� Moh� S-QA�A
ao- Loupo0 s(}e? �es0 " eate g�ts�oB.
011. Keq re c or& 3 y rs .
Tone, ac0'7 /�
w� &()
a`6o A Ica-- io(1 6IT'o T loRB U205 made-
tv� i rri�4dia�
ra�Hner�kPnan hones Z on - Nb �vera�pl�ca ion home
Page 3of3 10 Al d f-.XO-A15 A-)14 ) __fAr A1nJ 12128104

E Division of Water Quality
❑ Division of Soil and Water Conservation
❑ Other Agency
Facility Number : 850007 Facility Status: Active Permit: AW1850007 ❑ Denied Access
Inspection Type: Compliance Inspection Inactive or Closed Date:
Reason for Visit: Routine County: Stokes Region: Winston-Salem
Date of Visit: 01/18/2007 Entry TIme:09:35 AM Exit Time: 11,00 AM Incident #:
Farm Name: Providence Farm Owner Email:
Owner: Thomas K Shore Jr Phone: [phone]
Mailing Address: 1155 Providence Ln Pine Hall NC 270428130
Physical Address:
Facility Status: ❑ Compliant E Not Compliant Integrator:
Location of Farm: Latitude: 36°21'20" Longitude: 80°04'15"
From WSRO - US 311 North to Hwy 772. Turn left onto 772. Go 1 and 1/4 miles to owner's mail box (with name on top). Turn left
directly across road from the mailbox onto private lane and continue to, end of the lane.
Question Areas:
Discharges & Stream Impacts Waste Collection & Treatment Waste Application
Records and Documents Other Issues
Certified Operator: Thomas K Shore
Secondary OIC(s):
On -Site Representative(s): Name
On -site representative Thomas Shore
24 hour contact name Thomas Shore
Primary Inspector: M a R sebrock a� /
Inspector Signature:
Secondary Inspector(s):
Inspection Summary:
Operator Certification Number: 21439
Title
Phone
Phone: [phone]
Phone: [phone]
Phone:
Date:
4. Waste level is 2" over the bottom PVC pipe (maximum liquid mark). Need to pump, sample waste, and soil sample field(s) where
waste is applied. Soil test must be completed by 12/31/07. Must calibrate honey wagon used or obtain calibration documentation from
owner of honey wagon.
21. No waste applications since 2006. No 2006 soil or waste samples required.
20. Still need copy of WUP. Call DWQ if you need a copy.
21. Owner is not producing cheese. No whey or goat population records required today.
28. May need to revise WUP by removing 88 acres of bohomland, near Dan River. Mr. Shore lost lease to this land. Land is owned by
the Penn trust.
Page:1

Permit: AWI850007 Owner • Facility: Thomas K Shore Jr
Inspection Date: 0111812007 Inspection Type: Compliance Inspection
Facility Number: 850007
Reason for Visit: Routine
Regulated Operations Design Capacity Current Population
Cattle
Q Cattle - Milk Cow 240 0
Total Design Capacity: 240
Total SSLW: 336,000
Waste Structures
Type Identifier Closed Date Start Date Designed Freeboard Observed Freeboard
aste Pond WASTE POND I I 1 1 28.00
Page: 2

Permit: AW1850007 Owner- Facility: Thomas K Shore Jr
Inspection Date: 01/18/2007 Inspection Type: Compliance Inspection
Facility Number: 850007
Reason for Visit: Routine
Discharges 8& Stream Impacts
Yes
No
NA
NE
1. Is any discharge observed from any part of the operation?
❑
■
❑
❑
Discharge originated at:
Structure
❑
Application Field
❑
Other
❑
a. Was conveyance man-made?
❑
■
❑
❑
b. Did discharge reach Waters of the State? (if yes, notify DWO)
❑
■
❑
c. Estimated volume reaching surface waters?
d. Does discharge bypass the waste management system? (if yes, notify DWO)
❑
■
❑
❑
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 Waters of the State other than from a ❑
■
❑
❑
discharge?
Waste Collection, Storage & Treatment
Yoe
No
NA
NE
4. Is storage capacity less than adequate?
■
❑
❑
❑
If yes, is waste level into structural freeboard?
❑
5. Are there any immediate threats to the integrity of any of the structures observed (Le./ large trees, severe
❑
■
❑
❑
erosion, seepage, etc.)?
6. Are there structures on -site that are not properly addressed and/or managed through a waste management
❑
■
❑
❑
or closure plan?
7. Do any of the structures need maintenance or improvement?
❑
■
❑
❑
8. Do any of the structures lack adequate markers as required by the permit? (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 maintenance or
❑
■
❑
❑
improvement?
Waste Application Yes
No
NA
NE
10. Are there any required buffers, setbacks, or compliance alternatives that need maintenance or
❑
■
❑
❑
improvement?
11. Is there evidence of incorrect application?
❑
■
❑
❑
If yes, check the appropriate box below.
Excessive Ponding?
❑
Hydraulic Overload?
❑
Frozen Ground?
❑
- Heavy metals (Cu, Zn, etc)?
❑
Page: 3

Permit: AWI850007 Owner • Facility: Thomas K Shore Jr
Inspection Date: 01/18/2007 Inspection Type: Compliance Inspection
Facility Number: 850007
Reason for Visit: Routine
Waste Application
._......PAN?
Yes
No
NA
NE
❑
Is PAN > 10%/10 lbs.?
❑
Total P205?
❑
Failure to incorporate manure/sludge into bare soil?
❑
Outside of acceptable crop window?
❑
Evidence of wind drift?
❑
Application outside of application area?
❑
Crop Type 1
Fescue (Hay)
Crop Type 2
Crop Type 3
Crop Type 4
Crop Type 5
Crop Type 6
Soil Type 1
Soil Type 2
Soil Type 3
Soil Type 4
Soil Type 5
Soil Type 6
14. Do the receiving crops differ from those designated in the Certified Animal Waste Management
❑
■
❑
❑
Plan(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 acre determination? ❑
■
❑
❑
17. Does the facility lack adequate acreage for land application?
❑
■
D
❑
18, Is there a lack of properly operating waste application equipment?
❑
■
❑
❑
Records and Documents
Yes
No
NA
NE
19. Did the facility fail to have Certificate of Coverage and Permit readily available?
❑
■
❑
❑
20. Does the facility fail to have all components of the CAWMP readily available?
❑
■
❑
❑
If yes, check the appropriate box below.
WUP?
❑
Page: 4

Permit: AW1850007 Owner- Facility: Thomas K Shore Jr Facility Number: 850007
Inspection Date: 01/18/2007 Inspection Type: Compliance Inspection Reason for Visit: Routine
Records and Documents Yes No NA NE
Checklists? ❑
Design? ❑
Maps? ❑
Other? ❑
21. Does record keeping need improvement? ❑ IN ❑ ❑
If yes, check the appropriate box below.
Waste Application?
Cl
120 Minute inspections?
❑
Weather code?
❑
Weekly Freeboard?
❑
Transfers?
❑
Rainfall?
❑
Inspections after> 1 inch rainfall & monthly?
❑
Waste Analysis?
❑
Annual soil analysis?
❑
Crop yields?
❑
Stocking?
❑
Annual Certification Form (NPDES only)?
❑
22. Did the facility fail to install and maintain a rain gauge?
❑
IN
❑
❑
23. If selected, did the facility fail to install and maintain a rainbreaker on irrigation equipment (NPDES only)?
❑
■
❑
❑
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?
❑
IN
❑
❑
27, Did the facility fail to secure a phosphorous loss assessment (PLAT) certification?
❑
■
❑
❑
Other Issues
Yes
No
NA
NE
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 those
❑
E
❑
❑
mortality rates that exceed normal rates?
30. At the time of the inspection did the facility pose an air quality concern? If yes, contact a regional Air
❑
■
❑
❑
Quality representative immediately.
Page:5

Permit: AW1850007
Inspection Date: 01/18/2007
Owner- Facility: Thomas K Shore Jr
Inspection Type: Compliance Inspection
Other Issues
31. Did the facility fail to notify regional DWQ of emergency situations as required by Permit?
32. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
33. Does facility require a follow-up visit by same agency?
Facility Number: 850007
Reason for Visit: Routine
Yes No NA NE
❑■❑❑
❑ ■ ❑ ❑
❑ ■ ❑ ❑
Page: 6

N
yk Division of Water Quality
II Division of Sail and Water
O Other
Type of Visit
Compliance Inspection
O Operation Review O Structure Evaluation
O 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:
f® Departure Time: b0 County: �K�S Region: LOS P_
Farm Name: P V— V (A \0_nCP 1-6-r- Y1 Owner Email:
Owner Name: 1 k O YY) sy)6 r e— 1 Phone: _
Mailing Address: 11 fJ _S P r,) y' i PX1 C P - UaAl e-- (� _ i 1 112 H'4 11 1 NY� 0� 1 04,7—
Physical Address: r
Facility Contact: -VkOM S bo rP, Title: Phone No:
Onsite RepresentativeR �1U'311 �4rd 1 b - o ao3 t F
Certified Operator: y1 rjry1 Slime' Operator Certification Number:
Back-up Operator:
Location of Farm:
Back-up Certification Number:
Latitude: ®o ®' 0 " Longitude: ®o I V `B ' L g
us y 31i
no {-o L -7 5. Le
-H-oni-o 112,
'
06 Nw g D- 0, U Bus.
/S?eQG f U
66 north
31
+
Design Current '
Design - Current
Design
Current
Swine Capacity Population
Wet Poultry Capacity Population
Cattle Capacity
Population
❑ Wean to Finish
I ❑ Layer
EaDairy Cow
pZ 0
[]Wean to Feeder
❑Non -La er
U Dairy Calf
❑ Feeder to Finish
-
Dairy
❑tNon-Dai
" ❑ Farrow to Wean
❑ Farrow to Feeder
Dry Poultry
❑
❑Farrow
to Finish
❑ La ers❑❑Gilts
.❑ Non -La ers❑
Boars
Pullets❑❑
❑
--- - —
❑Turke s
-
Other
❑ Turkey Poults
❑ Other
❑ Other
Number of Structures:,
-�77�.
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 �No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes [:]No ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
12128104 Continued

Facility Number: S d'j . 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 I Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier: L 6P
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes No
ElNA
❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
�,,/,,
❑ Yes I No
❑ NA
El NE
through a waste management or closure plan?
I
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 14 No ❑ NA FINE
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 �Vo ❑ NA El NE
El Excessive Ponding El Hydraulic Overload El Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.) II
❑ 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)
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes 121No ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ? ❑ Yes
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
❑ Yes
❑ Yes
�Vo ❑ NA ❑ NE
❑ No �§ NA ❑ NE
jNo ❑ NA ❑ NE
XNo ❑ 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 access yl:
was+ 1n 6V �s at' �avt, �o{}�(AA Pv �
NOV - � t too
P�'�P�
�► �d� Where t LAAe 15 0 -A p l e- 11
5P0.;lWIW� �F, l
F, l J
(0 rQ� hoO uJ4 e n
Reviewer/Inspector Name r
Reviewer/Inspector Signatur
- -
jSa 5� r �
-- --
Phone: -lgam(' Sa g
Date: $ p
Page 2 of 3 0 ' L 12128104 Continued

Facility Number: S - Q7 Qate of Inspection I I$ 0 •
Reauired Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes Pj�'o ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check Yes ❑ No ❑ NA ❑ NE
the appropriate box. ❑ WUP ❑ Checklists ❑ Design ❑Maps El Other
21. Does record keeping need im vement?�^tirh ,.p•^P^^�^ u^-^•• . ❑ Yes �No ❑ NA ❑ NE
0_'W to A{rylietttierr Weekly Freeboard (I Witst�:� EP*mW4raasfers
Rainfall �Ockhm n�,-rie, n 4n n"-�.: WAO- P�� Trm Monthly and V Rain Inspections-B��
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes (7INo [I NA El NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? [I Yes 7�❑._,/No [XNA ❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit? El Yes I�No El NA ❑ NE
25. Did the facility fail to conduct a sludge survey as required by the permit? El Yes /❑ No VNA ❑ NE
26. Did the facility fail to have an actively certified operator in charge? ❑ Yes O No ❑ NA ❑ NE
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 XNA ❑ NE
[]Yes *o
❑ Yes �No
❑ Yes KNo
1A Yes ' ❑ No
❑ Yes �XNo
❑ Yes L]iN/o
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
El NA El NE
❑NA [I NE
Addi,tiW,pI Commentsand/or Drawings:
I`
�V 1 0 ► � n ! i / / l / ,1 ��
n r I
•r-_ �_�� J / 1 �, I �, / r �, it ./
i
0 m re,6 SQ uDuP * jj_^ X V U l� eh ore (Y�
kAJ�0)d
90 - '; 4- 1 I vw o ri n nn a c� W U a i CO )U00 U-O L / 01)
Page 3 of 3 1 1 t 12128104

0

l
Division of Water Quality
❑ Division of Soil and Water Conservation
❑ Other Agency
Facility Number: 850007 Facility Status: Active Permit: AW1850007 ❑ Denied Access
Inspection Type: Compliance Inspection Inactive or Closed Date:
Reason for Visit: Routine County: Stokes Region: Winston-Salem
Date of Visit: 12/18/2006 Entry Time: 09:30 AM Exit Time: 10,30 AM Incident #:
Farm Name: Providence Farm
Owner Email: _
88�
Owner: Thomas K Shore
Mailing Address: 1155 Providence Ln Pine Hall
Phone:
not l�o r VI, 1 curre.vlf'1
✓W
NC 270428130 J
Physical Address:
Facility Status: ❑ Compliant ❑ Not Compliant Integrator:
Location of Farm: Latitude: 36°21'20"
Longitude: 80°04'15"
From WSRO - US 311 North to Hwy 772. Turn left onto 772. Go 1 and 114 miles to owner's
mail box (with name on top). Turn left
directly across road from the mailbox onto private lane and continue to end of the lane.
Question Areas:
,
Discharges & Stream Impacts Waste Collection & Treatment
Waste Application
Records and Documents Other Issues
Certified Operator: Thomas K Shore Operator Certification Number: 21439
Secondary OIC(s):
On -Site Representative(s): Name Title
Phone
On -site representative Thomas Shore
Phone: 998iQ7-9894
3310.
q10.315 %
24 hour contact name Thomas Shore
Phone:
Primary Inspector: Ins ector: M I R s Brock
P \ �J
Phone: I h
e h e 0.t
Inspector Signature: "'�D I, Air 1, Air
/-
Date: Ia�I w
Secondary Inspector(s):
Inspection Summary:
18. Still borrowing honey wagon from Mark Shore (brother)?
21, No waste applied this year. No soil or waste samples required. No waste applications required.
21. Need to record rainfall and weekly waste level measurements per permit. Since no cattle are on site, stocking records not
required.
Page: 1

• .0
Permit: AW1850007 Owner- Facility: Thomas K Shore
Inspection Date: 12/18/2006 Inspection Type: Compliance Inspection
Facility Number: 850007
Reason for Visit: Routine
Regulated Operations Design Capacity Current Population
Cattle
O Cattle - Milk Cow 240 0
Other Animals
O Animals Other 15
Total Design Capacity: 240
Total SSLW: 336,000
Waste Structures
Type Identifier Closed Date Start Date Designed Freeboard Observed Freeboard
aste Pond WASTE POND 40.00
Page: 2

C�
C]
Permit: AW1850007 Owner - Facility: Thomas K Shore
Facility Number: 850007
Inspection Date: 12/18/2006 Inspection Type: Compliance Inspection Reason for Visit: Routine
Discharges & Stream Impacts I Yes No NA NE
1. Is any discharge observed from any part of the operation? ❑ ■ ❑ ❑
Discharge originated at
Structure
- ❑
Application Field
❑
Other
❑
a. Was conveyance man-made?
❑
■ ❑
❑
b. Did discharge reach Waters of the State? (if yes, notify DWQ)
❑
■ ❑
❑
c. Estimated volume reaching surface waters?
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 Waters of the Slate other than from a
❑
■
❑
❑
discharge?
Waste Collection, Storage & Treatment Yes
No
NA
NE
4. Is storage capacity less than adequate?
❑
■
❑
❑
If yes, is waste level into structural freeboard?
❑
5. Are there any immediate threats to the integrity of any of the structures observed (Le./ large trees, severe
❑
■
❑
❑
erosion, seepage, etc.)?
6. Are there structures on -site that are not properly addressed and/or managed through a waste management
01111111111100
or closure plan?
7. Do any of the structures need maintenance or improvement?
❑
■
❑
❑
8. Do any of the structures lack adequate markers as required by the permit? (Not applicable to roofed pits,
0
■
❑
❑
dry stacks and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require maintenance or
❑
■
❑
❑
improvement?
Waste Application
Yes
No
NA
NE
10, Are there any required buffers, setbacks, or compliance alternatives that need maintenance or
❑
■
❑
❑
improvement?
11. Is there evidence of incorrect application?
❑
■
❑
❑
If yes, check the appropriate box below.
Excessive Ponding? ❑
Hydraulic Overload? ❑
Frozen Ground? ❑
Heavy metals (Cu, Zn, etc)? ❑
Page: 3
n

• 0
Permit: AW1850007 Owner- Facility: Thomas K Shore
Facility Number: 850007
Inspection Data: 12/18/2006 Inspection Type: Compliance Inspection
Reason for Visit: Routine
Waste Application
Yes No NA NE
PAN?
❑
Is PAN > 10%/10 lbs.?
Cl
Total P205?
❑
Failure to incorporate manure/sludge into bare soil?
❑
Outside of acceptable crop window?
❑
Evidence of wind drift?
❑
Application outside of application area?
❑
Crop Type 1
Fescue (Hay)
Crop Type 2
Crop Type 3
Crop Type 4
Crop Type 5
Crop Type 6
Soil Type 1
Soil Type 2
Soil Type 3
Soil Type 4
Soil Type 5
Soil Type 6
14. Do the receiving crops differ from those designated in the Certified Animal Waste Management
Plan(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 acre determination?
W. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
Records and Documents
19, Did the facility fail to have Certificate of Coverage and Permit readily available?
20. Does the facility fail to have all components of the CAWMP readily available?
If yes, check t'he appropriate box below.
WUP?
❑ ■ Cl ❑
❑ ■ ❑ ❑
❑ ❑ ■ ❑
❑ ■ ❑ ❑
❑ ❑ ❑ ■
Yea No NA NE
■ ❑ ❑ ❑
■. ❑ ❑ ❑
C
Page: 4

Permit: AW1850007 Owner- Facility: Thomas K Shore
Inspection Date: 12/18/2006 Inspection Type: Compliance Inspection
Facility Number: 850007
Reason for Visit: Routine
Records and Documents
Yes No NA NE
Checklists?
❑
Design?
❑
Maps?
❑
Other?
❑
21. Does record keeping need improvement?
■ ❑ ❑� ❑
If yes, check the appropriate box below.
Waste Application?
❑
120 Minute inspections?
❑
Weather code?
Weekly Freeboard?
■
Transfers?
❑
Rainfall?
■
Inspections after> 1 inch rainfall 8. monthly?
■
Waste Analysis?
❑
Annual soil analysis?
❑
Crop yields?
❑
Stocking?
❑
Annual Certification Form (NPDES only)?
❑
22. Did the facility fail to install and maintain a rain gauge?
❑
■
❑
❑
23. If selected, did the facility fail to install and maintain a rainbreaker on irrigation equipment (NPDES only)?
❑
❑
■
❑
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑
Cl
■
❑
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 phosphorous loss assessment (PLAT) certification?
❑
❑
■
❑
Other Issues
Yes
No
NA
NE
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 those
❑
■
❑
❑
mortality rates that exceed normal rates?
30. At the time of the inspection did the facility pose an air quality concem? If yes, contact a regional Air
❑
■
❑
❑
Quality representative immediately.
Page:5

a
Permit: AW1850007 Owner - Facility: Thomas K Shore
Facility Number: 850007
Inspection Date: 12/18/2006 Inspection Type: Compliance Inspection Reason for Visit: Routine
Other Issues Yes No NA NE
31. Did the facility fail to notify regional DWQ of emergency situations as required by Permit?
32. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
33. Does facility require a follow-up visit by same agency?
m■RE]
❑ ■ ❑ ❑
❑ ■ ❑ ❑
Page: 6

Division of Water Quality •
Facility Number Division of Soil and Water Conservation 30
�pther Agency
IType of Visit qkCompliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance I
Reason for Visit Routine 0 Complaint Q Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: d rrival Time: Departure Time: 1® County: Region: w9eb
Farm Name: (.j C P FaAr-tV1 Owner Email:
Owner Name: "•J1 1'�O' cA �S -- karf / � n Phone:
Mailing Address: 11�.�
Physical Address: ,�AA4_0
Facility Contact: r66 t4 Title: Phone No:
Onsite Representative: tj 11 q Q Id .91-6 a 03 Integrator:
Certified Operator: I V o ima 5 )�_• 56ff� Operator Certification Number: a N 3
Back-up Operator:
Location of Farm:
Back-up Certification Number:
Latitude: ®e ®, a& Longitude: RN°EZ11 11
Design
Current
Design.' Current°:`
Design ` Current'
Swine - Capacity
Population .Wet Poultry
Capacity"Population '';Cattle
Capacity Population
❑ Wean to Finish
' ❑ Layer
I
❑ Dairy Cow
❑ Wean to Feeder
i- ❑ Non -Layer
I
❑ Dairy Calf
❑ Feeder to Finish
❑ Dairy Heifer
❑ Farrow to Wean
r Dry Poultry
❑ Dry Cow
❑ Farrow to Feeder
" ❑ Non -Dairy
ElFarrow to Finish
❑ La ers
❑ Beef Stocker
❑ Gilts
❑ Non -Layers
-"
❑Beef Feeder
LEA
❑ Boars
❑Pullets
❑ Beef Brood Cow
—
— ❑ Turkeys
❑ Turkey Poults
Other
0 Other
Number of Structures: ED ,
11
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
❑ Yes
[ (No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
[]No
❑ NA
❑ NE
0
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes ,1�6,.,1 NNo El NA [I NE
ElL�QYo Yes / `❑ NA ❑ NE
11/18104 Continued

FacilityNumber: S— • Date of Inspection •
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Structure 1 Structure 2 Structure 3 Structure 4
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): V
5. Are there any immediate threats to the integrity of any of the structures observed?
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
through a waste management or closure plan?
❑ Yes ANo
ElYes ❑No
Structure 5
❑ NA ❑ NE
❑NA El NE
Structure 6
❑ Yes o ❑ NA ❑ NE
❑ Yes #No ❑ NA ❑ NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes No El NA El NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes _VNo ❑ 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 KNo ElNA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ YesNo ❑ NA El NE
❑ Excessive Ponding El Hydraulic Overload El 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)
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes 4No ❑ 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
XNo
❑ NA ❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
❑ No
❑ NA ) q NE
Comments (refer to question#): Explain any YES answers and/or any recommendations, or any other comments.
Use drawings of facility to better explain situations. (use additional pages as necessary):
Reviewer/Inspector Name I O 5 r Phone: —
Reviewer/Inspector Signature: Date:
Page 2 of 3 1 - V , 1' 12128104 Continued

Facility Number: —0 leate of Inspection I / •
Required Records & Documents �[
19. Did the facility fail to have Certificate of Coverage & Permit readily available? IFIYes ❑ No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check Yes El No ❑ NA ❑ NE
the appropriate box. ❑ WUP ❑ Checklists ❑ Design El Maps El Other +�,/
21. Doe record keeping need im rovement? tfyes, t,_hee,QQj4 he appropriate box by ow. ayes ❑ No ❑ NA ❑ NE
W aste Applicat{ion need
Freeboard E W�e Analysis LSo���li}}}�nalysis EWaste Transfers
Rainfall �6FAMng �� Yield t�+speetiens Monthly and V Rain Inspections
( amerc-ode-
22. Did the facility failtoinstall and maintain a rain gauge? Yes l�l No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? El Yes /❑`No
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?
lAdditional Comments and/or Drawines:
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑l No
❑ Yes Ij No
❑ Yes /❑ No
❑ Yes VNo
❑ Yes No
❑ Yes ko
❑ Yes [ No
❑ NA ❑ NE
IN
A El NE
A ❑NE
A ❑ NE
❑ NA VNE
�(NA ❑ NE
❑ NA ❑ NE
�(NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
El NA ❑NE
E�J we" v�0,-5+e 1 enEe
re C.o r� 5
Nv wa5-42p(ie�e n�5���-r- No f S�1� or(
l /WOL 1te, Sa4 ley f ��v b fe j m
Page 3 of 3 12128104

❑ Division of Water Quality
❑ Division of Soil and Water Conservation
❑ Other Agency
Facility Number: 850007 Facility Status: Active Permit: AW1850007 ❑ Denied Access
Inspection Type: Compliance Inspection Inactive or Closed Date:
Reason for Visit: Routine County: Stokes Reglon: Winston-Salem Ow
Date of Visit: 02/09/2005 Entry Time: 01,05 PM Exit Time: 03,30 PM
Farm Name: Providence Farm
Mailing Address: 1155 Providence Ln
Physical Address:
Facility Status: ❑ Compliant ❑ Not Compliant Integrator:
o,
Owner Email: jpa\q
Location of Farm: Latitude: 36.36 Longitude: -80.07
From WSRO - US 311 North to Hwy 772. Turn left onto 772. Go 1 and 1/4 miles to owners mail box (with name on top). Turn left
directly across road from the mailbox onto private lane and continue to end of the lane.
Question Areas:
0 Discharges & Stream Impacts
0 Records and Documents
Waste Collection & Treatment Waste Application
0 Other issues
Certified Operator: Thomas K Shore Operator Certification Number: 21439
Secondary OIC(s):
On -Site Representative(s): Name
Title Phone
24 hour contact name Thomas Shore
Phone: [phone]
On -site representative Thomas Shore
Phone: [phone]
Primary Inspector: Mary M Rosebrock
Phone:[phone]
Ext.383
Secondary Inspector(s):
Phone:
Phone:
Inspection Summary:
8. Operator does not have marker yet.
18. Owner shares equipment with his brother, mark Shore.
21. Per permit, need to record weekly whey production.
There are only 19 goats onsite while the permit states that there are to be 25. Operator staled that there would be 25 by this spring
since some had not been born yet.
Need to record all rain/snow events.
28. Operator has been irrigating some waste but the CAWMP is only for broadcast applications. Must cease irrigation or revise waste
plan.
2004 soil test results look ok.
Page: 1

• o
Permit: AW1850007 Owner- Facility: Thomas K Shore Facility Number: 850007
Inspection Date: 02/09/2005 Inspection Type: Compllance Inspection Reason for Visit: Routine
Regulated Operations
Design Capacity Current Population
Cattle
® Cattle -Milk Cow 240 19
Total Design Capacity: 240
Total SSLW: 336,000
Page: 2

Permit: AWI850007 Owner- Facility: Thomas K Shore Facility Number: 850007
Inspection Date: 02/09/2005 Inspection Type: Compliance Inspection Reason for Visit; Routine
Waste Structures
Num Desc
Close Dt Start Dt Designed Freeboard Observed Freeboard
WASTE PO I Waste Pond I I 1 1 48.00
Page: 3

0
0
Permit: AW1850007 Owner - Facility: Thomas K Shore Facility Number:
Inspection Date: 02/09/2005 Inspection Type: Compliance Inspection Reason for Visit:
850007
Routine
Discharaes R Stream Impacts.
1. Is any discharge observed from any part of the operation?
Yes_
❑
No
M
NA
❑
NE
❑
Discharge originated at:
Structure
❑
Application Field
❑
Other
❑
a. Was conveyance man-made?
❑
❑
❑
b. Did discharge reach Waters of the State? (if yes, notify DWQ)
❑
M
❑
❑
c. Estimated volume reaching surface waters?
d. Does discharge bypass the waste management system? (if yes, notify DWQ)
❑
0
❑
❑
2. Is there evidence of a past discharge from any part of the operation?
❑
M
❑
❑
3. Were there any adverse impacts or potential adverse impacts to Waters of the State other than from a discharge?
0
Yes
M
No
❑
NA
❑
NE
Wasfp Coilp.Ctinn_ Storage & Treatment
4. Is storage capacity less than adequate?
❑
M ❑
❑
If yes, is waste level into structural freeboard?
❑
5. Are there any immediate threats to the integrity of any of the structures observed (I.e./ large trees, severe erosion,
❑
0
❑
❑
seepage, etc.)?
6. Are there structures on -site that are not properly addressed and/or managed through a waste management or
❑
0
❑
❑
closure plan?
7. Do any of the structures need maintenance or improvement?
❑
M
❑
❑
8. Do any of the structures lack adequate markers as required by the permit? (Not applicable to roofed pits, dry stacks
❑
❑
❑
and/or wet stacks)
9. Does any pan of the waste management system other than the waste structures require maintenance or
❑
M
❑
❑
improvement?
Vas
No
NA
NF
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need maintenance or improvement?
❑
0
❑
❑
11. Is there evidence of incorrect application?
❑
M
❑
❑
If yes, check the appropriate box below.
Excessive Ponding?
❑
Hydraulic Overload?
❑
Frozen Ground?
❑
Heavy metals (Cu, Zn, etc)?
❑
PAN?
❑
Is PAN > '10%/10 lbs.?
❑
Total P2O5?
❑
Failure to incorporate manure/sludge into bare soil?
❑
Outside of acceptable crop window?
❑
Evidence of wind drift?
Cl
Application outside of application area?
❑
Crop Type 1
Fescue (Pasture)
Crop Type 2
Crop Type 3
Crop Type 4
Crop Type 5
Page: 4

Permit: AW1850007 Owner- Facility: Thomas K Shore
Facility Number: 850007
Inspection Date: 02/09/2005 Inspection Type: Compliance Inspection
Reason for Visit: Routine
Yes No NA NF
Waste tr fi ^tion
Crop Type 6
-
Soil Type 1
Soil Type 2
Soil Type 3
Soil Type 4
Soil Type 5
Soil Type 6
14. Do the receiving crops differ from those designated In the Certified Animal Waste Management Plan(CAWMP)? ❑
0 ❑
❑
15. Does the receiving crop and/or land application site need improvement?
❑
0 ❑
❑
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?
❑
❑ 0
❑
17. Does the facility lack adequate acreage for land application?
❑
0 ❑
❑
18. Is there a lack of properly operating waste application equipment?
❑
Yes
0 ❑
No NA
❑
NF
Rennrds and Documents
19. Did the facility fail to have Certificate of Coverage and Pennit readily available?
❑
0 ❑
❑
20. Does the facility fail to have all components of the CAWMP readily available?
❑
0 ❑
❑
If yes, check the appropriate box below.
WUP?
❑
Checklists?
❑
Design?
❑
Maps?
❑
Other?
❑
21. Does record keeping need improvement?
❑ ❑
❑
If yes, check the appropriate box below.
Waste Application?
❑
120 Minute inspections?
❑
Weather code?
0
Weekly Freeboard?
❑
Transfers?
❑
Rainfall?
Inspections after> 1 inch rainfall 8 monthly?
Waste Analysis?
❑
Annual soil analysis?
❑
Crop yields?
❑
Stocking?
❑
Annual Certification Form (NPOES only)?
❑
22. Did the facility fail to install and maintain a rain gauge?
❑
❑
❑
23. If selected, did the facility fail to install and maintain a rainbreaker on Irrigation equipment (NPDES only)?
❑
0 ❑
❑
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑
0 ❑
❑
25. Did the facility fail to conduct a sludge survey as required by the permit?
❑
❑ E
❑
26. Did the facility fail to have an actively certified operator in charge?
❑
E ❑
❑
27. Did the facility fail to secure a phosphorous loss assessment (PLAT) certification?
❑
❑ 0
❑
Page: 5

•
0
Permit: AWI850007 Owner- Facility: Thomas K Shore
Facility Number: 850007
Inspection Date: 02/09/2005 Inspection Type: Compliance Inspection Reason for Visit: Routine
Other Issues Vas No NA NE
28, Were any additional problems noted which cause non-compliance of the Permit or CAWMP7 0 ❑ ❑ ❑
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document and report those mortality ❑ M ❑ ❑
rates that exceed normal rates?
30, Al the time of the Inspection did the facility pose an air quality concern? If yes, contact a regional Air Quality 0000
representative immediately.
31. Did the facility fail to notify regional DWQ of emergency situations as required by Permit?
❑
0 ❑
❑
32. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑
0 1113
33. Does facility require a follow-up visit by same agency?
❑
E ❑
❑
Page: 6

ON
Type of Visit
Reason for V
Date of Visit:
Farm Name:
Owner Name:
Compliance Inspection
Routine 0 Complaint
Arrival Time:
0 Operation Review 0 Structure Evaluation 0 Technical Assistance
0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Departure Time: 3O County:
Mailing Address: h.D:) I" F U V I Ut-V V I l t' I, �L l t C_
Physical Address: ��,�IJ
Facility Contact: I Y'^ d Ol i n S h(( )Ce Title:
Onsite Representative: a nfiEe
Certified Operator:n OLf,
fN1/ 1
Back-up Operator: /A
ocAtion of Farm:
U, 1 :l 311 nOrih tt
1 `/4 m t l-s m le R
Swine
Other
❑ Other
Latitude: 0
l 11. LtF
�
Region: �)O
J Ip`-
Owner Email: // �//
_ Phone: 3310 • Td7 ' �77 g �_
Pine- 1-4 (1 N C- a 70 V,—_
Phone No: C41 8 W *F2
Integrator:
Operator Certification Number: —;Q 14 =i-
Back-up Certification Number:
M I ® 11 Longitude: ®o W' Er
onfo !may 11 a . FOXM 1S
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer
❑ Non -Layer j
Dry Poultry
❑ La ers
❑ 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)?
Design Current
Capacity Population
10
Number of Structu es: FT
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 L (o ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
0
❑ NA
❑ NE
❑ Yes
❑ o
❑ Yes
7No
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
12128104
Continued
l,5 00 p. P

Facility Number: — • Date of Inspection •
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes WNo
❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ NA ❑ NE
Structure StructureStructure 3 Structure 4 Structure 5 Structure 6
Identifier.
Spillway?: Z S
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes �o ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ YesJo ❑ 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 I,$,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 *o El NA El NE
maintenance or improvement? // ``
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes No ❑ NA ❑ NE
maintenance/improvement? �No
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes ❑ NA ❑ NE
ElExcessive Ponding ElHydraulic 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) V r
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
No
ElNA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
jNo
❑ 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?
El
No
/
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
No
❑ NA
❑ NE
lea e" KID �: �yop tAu- P
Reviewer/Inspector Name Phone: I I •4 4 U 6 0—&t
Reviewer/InspectorSignat AZ Date: `�

Facility~ Number: — DJ*f Inspection Ii� IH [(JJ •
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes o ❑ NA ❑ NE
20. Does the facility fail to have all c nponents the CAWM�adily avail le? Ifyes, check ❑ Yes W No ❑ NA ❑ NE
the appropirate box. ❑ UP ❑ C tecklists ! ❑ Design ❑ aps ❑ Other
21. poes record keeping need impr ement? If yes, check the appropriate box below. II p�Yes
✓❑ Waste Application ❑ Wee�klyl eeboard ❑ Waste Analysis ❑ Soil Analysis ❑ W�tlltansfer
�] Rainfall ❑ sw ing ❑ C�fop Yield ❑ 120 MimiVi rtlS�ections I� Monthly and I
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?
❑No El NA yy�O,NE
s ❑ Annuuvy/thcation
Rainlnspections KWeatherCode
❑ Yes
No
El NA
❑ NE
El Yes
/*0
❑ NA
❑ NE
❑ Yes
P(No
❑ NA
❑ NE
❑ Yes
❑ No
X NA
❑ NE
❑ Yes
❑ No
t NA
El NE
El Yes
El No
DLI NA
❑ NE
Yes
❑ No
❑ NA
❑ NE
❑ Yes
KNo
❑ NA
❑ NE
❑ Yes
KNo
❑ NA
❑ NE
❑ Yes
)<No
❑ NA
❑ NE
❑ Yes
ANo
❑ NA
❑ NE
❑ Yes
�No
❑ NA
❑ NE
Ad itional Comments and/or Drawings:
aI. 5{e S iPly LA_/in 6;0 c o 'etfp1ic �r� `3Is/o�/ lei 16s
Frboaurd ?' i,�r� UQ-a° tt� whe�? N 0
COO)I,v 1� GoLZ
g
m C 5 Lo Cb ®-r-LO Q�
Need im irecoCA a(i routh150)OUJ ow-e-tS
12128104

Date of Visit: 1/29/2004 Time 1200
Facility Number 85 7
Q Not Operational 0 BelowThreshold
Permitted M Certified 0 Conditionally Certified [3 Registered Date Last Operated or Above Threshold:
Faun Name: P.ruidgm.Farm.................................................................. County: Stalim ..................................... ) ,&&Q......
Owner Name. Thutnas----------------- Sho�A --•-.---•---------.-.---.-.-. Phone No: 33fi=42ZSZ48.HOroe .-•---.-.-.---._._._..
Mailing Address: .1.1S.S..Prnxideace..Lane...................................................................... Pine.Ha11.�C.......................................................... Z7.0.42 ..............
Facility Contact: .T.homas.Shnre....................................Title:............................................... Phone No: 427.9&Q4.........................
Onsite Representative:'fJtOl0a5-Shl]Ce-----------------•-----•-----•-----•-• Integrator:._.-•---•---------•-•---------•-------•---..
Certified Operator:ThOJIRaSA ............................ >�hOC.e.JX........................................... Operator Certification Mother: 21..3.9..............................
Location of Farm:
7rom WSRO - US 311 North to Hwy 772. Turn left onto 772. Go 1 and 1/4 miles to owner's mail box (with name on top).
Turn left directly across road from the mailbox onto private lane and continue to end of the lane.
❑ Swine [3Poultry ® Cattle [IHorse Latitude 36 OF 21 F 207 Longitude F807 OF 04 F15
y ±=Designs'
`Curjrenf'/I)'e`sign
Current x;4�Deslgn;a Current
a�iona Cattle "ulation��
^Swine-b,�. �
Capacity',,,Po uliition
,Poultry �_ , y�Ca a It Po Ca aci P.o
❑ Wean to Feeder
❑ Layer : ® Dairy 240 20
❑ Feeder to Finish
; ❑ Non -Layer
r' ❑Non -Dairy
❑ Farrow to Wean
q r warn x a
�.
❑Farrow to Feeder
❑ Other
❑ Farrow to Finish
'v�'£t' ;: jTO�IUD¢ gn Capacity t 240
❑ Gilts
'Total'SSLW; 336,000
❑ Boars
xM
t Number`tof La bonsrs 0 ^r iAjL-
Discharees & Stream Impacts
1. 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 adverse 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 I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier....WAStI:.=i .... .........................................................................................................-- ...........................
Freeboard (inches): 18
12112103 Continued

Facility Number: 85-7 Date of Inspection 1/29/2004
5.
Are there any immediate threats to the in egrity 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
®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 maintenance/improvement?
❑ Yes
®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
❑ No
elevation markings?
Waste Application
10.
Are there any buffers that need maintenance/improvement?
❑ Yes
®No
It.
Is there evidence of over application? If yes, check the appropriate box below.
❑ Yes
® No
❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload ❑ Frozen Ground ❑ Copper and/or Zinc
12.
Crop type Fescue (Graze)
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?
❑ Yes
® No
b) Does the facility need a wettable acre determination?
❑ Yes
® No
c) This facility is pended for a wettable acre determination?
❑ Yes
®No
15.
Does the receiving crop need improvement?
❑ Yes
® No
16.
Is there a lack of adequate waste application equipment?
❑ Yes
®No
Odor Issues
17. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below ❑ Yes ® No
liquid level of lagoon or storage pond with no agitation?
18. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes ® No
19. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt, ❑ Yes ® No
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 ❑ Yes ® No
Air Quality representative immediately.
o ents refer R It #): Explain any ES an a and/or any recommendations or an. other comments.
drawings of fae;i to better explain situations. u additional ages as necessary : ❑Field Copy NFinal Notes
4. Need to apply waste as soon as possible. Waste level is only 1-2 inches below the parlor pipe.
9. Per permit, the marker should have been installed over three years ago. Needs to be installed as soon as possible.
15. If a crop receives animal waste it must be removed by harvesting or through grazing.
1. DWQ to send another copy of the COC and permit.
23. Waste sample needs to be obtained within 60 days of application. July 2003 applications did not have waste analysis within 60 days.
Check next visit.
23. Must begin recording waste freeboard each week, per permit. Check next visit.
Facility requested to be removed from the registration list after permit was issued 8113199 so request was denied. Facility must abide
by the permit until the WSP is elosedper NRCS standards. Operator still plans to manufacture cheese onsite and will need to obtain
an Individual Waste Permit to put the washwater from the pasteurizer into the WSP. The whey is to be fed to swine to be kept on site in
existing barns.
Reviewer/inspector Name Meli Rosebrock
Reviewer/Inspector Signature: Date:
I2112103 Cantinued

Facility Number: 85-7 1)if Inspection 1/29/2004 •
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
❑ No
❑ Waste Application ® Freeboard IN 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/inspection with on -site representative?
❑ Yes
® No
28.
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
®No
NPDES
Permitted Facilities
30.
Is the facility covered under a NPDES Permit? (If no, skip questions 31-35)
❑ 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
❑ No
33.
Did the facility fail to conduct an annual sludge survey?
❑ Yes
❑ 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 I" 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.
;•d8it"ionaRComments and%o RMRin¢s:
12112103
12112103

Fa
10
Type of Visit 8J Compliance Inspection 0 Operation Review 0 Lagoon Evaluation
Reason for Visit [` Routine 0 Complaint 0 Follow up 0 Emergency Notification 0 Other ❑ Denied Access
Facility Number Date of Visit: 0 Time: t�
10 Not O erational 0 Below Threshold
ty Permitted (Certified . 0 0 Conditionally Certified Registered Date Last Operated or Above Threshold:
Farm Name: mot'iby134,nLt- FArM Countv:_�t�%
Owner Name: MQC,1.040s Phone No: J �r
Mailing Address: i ,r� . I %� j I
i
Facility Contact: �rl,ry Title: Phone No:
Onsite Representative: O / Integrator: Certified Operator: -Mp a 5 hn IrvOperator Certification Number: '� �Lt 3
Location of Farm:
❑ Swine ❑ Poultry cattle ❑ Horse Latitude E2TLI'' aFJ• ®•• Longitude [=' F-M• `---/r ,,
Swine
Design
Capacity
Current
Population
Design Current Design Current
Poultr Capacity Population C le Ca tacit Population
❑ La cr Dai
❑ Non -La cr I 1 10 Non -Dairy
--
❑ O[her,-
Total Design Capacity 4
Total SSLW
El Wean to Feeder
❑ Feeder to Finish
�',
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Giits
f1 Rna s
Discharges & Stream Impacts ,,,,,,,,,(((
1. Is any discharge observed from any part of the operation? El Yes No
Discharge originated at: ❑ Lagoon ❑ Spray Field El Other
a. If discharge is observed, was the conveyance man-made? ❑ Yes ❑ No
b. If discharge is observed, did it reach Water of the Slate? (1 f 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 ycs, notify DWQ) ❑ Yes ❑ No
2. Is there evidence of past discharge from any part of the operation? ❑ Yes No
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes >Jo
Waste Collection & Treatment �,,/
4. Is storage capacity (freeboard plus storm storage) less than adequate? Spillway El Yes I.XI No
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6 7�
Identifier: 1 6 n�.
Freeboard (inches): W
05103101 p Continued
4nlrvlaj lva54e.-KeliSSgnog bavd 2U55ell fell
Oro (i-o-,P6)

• •
Facility Number: s— Date of Inspection
5.
Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion,
❑ Yes
ylyN0
seepage, etc.)
,
/
6.
Are there structures on -site which are not properly addressed and/or managed through a waste management or
closure plan?
(If any of questions 4-6 was answered yes, and the situation poses an
❑ Yes
LV ,No
immediate public health or environmental threat, notify DWQ)
7.
Do any of the structures need maintenance/improvement?
❑ Yes
o
8.
Does any pan of the waste management system other than waste structures require maintenance/improvement?
❑ Yes
PNo
9.
Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings?
Yes
❑ No
Waste Application
10.
Are there any buffers that need maintenance/improvement?
❑ Yes
No
11.
Is there evidence of over application? ❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload
❑ Yes
������ ....,,,,,((((
�No
12.
Crop type 410 l 10 itClA Z e-
13.
Do the receiving crops differ with those dNinited in the dritified Animal Waste Management Plan (CAWMP)?
❑ Yes
)�No
14.
a) Does the facility lack adequate acreage for land application?
❑ Yes
o
b) Does the faciliry need a wettable acre determination?
El Yes
c) This facility is pended for a wettable acre determination?
ElYeso
jNo
15.
Does the receiving crop need improvement?
❑ Yes
o
16.
Is there a lack of adequate waste application equipment?
❑ Yes
���...///
1g No
Reouired
Records & Documents
/
17.
Fail to have Certificate of Coverage & General Permit or other Permit readily available?
Yes
❑ No
18.
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
19.
Does record keeping need improvement? (ie/ irrigation. frlard, waste analysis & soil sample reports)
XYes
❑ No
20.
Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑Yes
No
21.
Did the facility fail to have a actively certified operator in charge?
❑ Yes
No
22.
Fail to notify regional DWQ of emergency situations as required by General Permit?
(,
(ie' discharge, freeboard problems, over application)
❑ Yes
No
23.
Did Reviewer/Inspector fad to discuss review/inspection with on -site representative?
❑ Yes
(((jjj"""%Q%%
�N
24.
Does facility require afollow-up visit by same agency?❑
YesNo
I
25.
Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑YesNo
0 No violations or deficiencies were noted during this visit. You will receive no further correspondence about this visit.
Comment.",(rrrvefer to g"o"esto¢ •...�lan YES, r%t rspany,5CCLW If�AW '+bvtYLkKT: �, it.'t da rnt �"`�JH 4. 4+"YS. nY UU ,t r x
or any, recommendations or any Mher comme¢tsd t,
Use drawings of facility to better explain situations (use additional pages as necessary)
Field Copy ❑ Final Noes
�il.Q �e.�� t� incc9z >✓-G��.u.c� .��
Reviewer/Inspector Name f, I_ .y,�,.,.,,t�;
Reviewer/Inspector Signature: Date:

Facility Number: — Date of Inspection •
Odor Issues
26. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of properly within 24 hours?
28. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt,
roads, building structure, and/or public property)
29. Is the land application spray system intake not located near the liquid surface of the lagoon?
30. Were any major maintenance problems with the ventilation fan(s) noted? (i.e. broken fan belts, missing or
or broken fan blade(s), inoperable shutters, etc.)
31. Do the animals feed storage bins fail to have appropriate cover?
32. Do the flush tanks lack a submerged fill pipe or a permanent/temporary cover?
Aqw-�-14
❑ Yes 0No
❑ Yes No
/I A U-SlAb Imo/
t /l / l
r

,amt"-4 C4L)
a4-e-h
� v
ell.

Type of Visit O Compliance Inspection O Operation Review O Lagoon Evaluation
Reason for Visit O Routine O Complaint p Follow up O Emergency Notification O Other ❑ Denied Access
Facility Number 85 7 Date ut Visit: 5l31/2002. Time: 1215
O Not Operational 0 Below Threshold
Permitted 0 Certified 17 Conditionally Certified E3 Registered Date Last Operated or Above Threshold: 91911.R97........
Farm Name: Proxidettse..k'st'm......................................................................................... County: S.tokca ................................................ W
SRO ........
OwnerName: ThAxnas.................................. Shorg ........................................................... Phone No: 3abr.427-5.7.98....................................:......................
Mailing Address: 11SS..Ptaxldetut.l�atte.............................:....................................... flike-HARAC ......................................................... 27Q.Q .............
Facility Contact: Thomas.Short............................................... Title:................................................................ Phone No:...................................................
Onsite Representative: :�ltQIl00S.S11A.C1:.......................................:...: Integrator:......................................................................................
Certified Operator:;h',(Mppas„jL........................... SIIlt[Rjr.......................................... Operator Certification Number:21439 .............................
Location of Farm:
From WSRO - US 311 North to Hwy 772. Turn left onto 772. Go 1 and 1/4 miles to owner's mail box (with name on top). A
turn left directly across road from the mailbox onto private lane and continue to end of the lane.
❑ Swine ❑ Poultry ® Cattle ❑ Horse Latitude 36 • 21 207 Longitude F 80 • ® 15
1 isch. rrges &C Stream
1. 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 Stale? (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 adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes ® No
Waste Collection's 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: .......Waste.P.ond.....................................................................................................................................................................................
Freeboard (inches): 30
05103101 Continued

Facility Number: 85-7 Date of Inspection 5/31/2002
5. Are there any immediate threats to the int grity of any of the structures observed? (ie/ tree`s'Srevere erosion,
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or
closure plan?
(If any of questions 4.6 was answered yes, and the situation poses an
immediate public health or environmental threat, notify DWQ)
7. Do any of the structures need maintenance/improvement?
8. Does any part of the waste management system other than waste structures require maintenance/improvement?
9. Do any stuctures hack adequate, gauged markers with required maximum and minimum liquid level
elevation markings?
Waste Application
10. Are there any buffers that need maintenance/improvement?
11. Is there evidence of over application? ❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload
12. Crop type
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)?
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?
Required Records & Documents '
17. Fail to have Certificate of Coverage & General Permit or other Permit readily available?
18. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.)
19. Does record keeping need improvement? (ie/ irrigation, freeboard, waste analysis & soil sample reports)
20. Is facility not in compliance with any applicable setback criteria in effect at the time of design?
21. Did the facility fail to have a actively certified operator in charge?
22. Fail to notify regional DWQ of emergency situations as required by General Permit?
(ie/ discharge, freeboard problems, over application)
23. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
24. Does facility require a follow-up visit by same agency?
❑ Yes
® No
❑ Yes
® No
® Yes
❑ No
❑ Yes
® No
❑ Yes
❑ No
❑ Yes
❑ No
❑ Yes
❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ® No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ® No
® Yes ❑ No
25. Were any additional problems noted which cause noncompliance of the Certified AWMP? ❑ Yes ❑ No
No violations or deficiencies were noted during this visit. You will receive no further correspondence about this visit.
❑ Field Copy ® Final Notes
Discharge of graywater from pipe coming from mobile home washing machine was noted again this year. Discharge was actually
wing during inspection and had traveled 210 feet to reach an intermittent stream that had puddles of water in it but was not Flowing.
:charge was reported to Stokes Co. Environmental Health (Jim Oakley) on 2/20/01. Called Heather Hicks (new Supervisor for
vironmental Health) and she said that she would look at facility on 613/02 or 6/4/02. Her number is 336.983.0421
Discharge has been continuing since at least 2/20/01.
Need to continue efforts to mow vegetation on and around waste storage pond and control groundhogs and repair burrow holes.
Need to check waste storage pond levels periodically and to see if graywater discharge is eliminated.
Reviewer/Inspector Name iM
Reviewer/Inspector Signature:
Date:
05103101 Continued

�. Facility Number: 85-7 Daf Inspection 5/31/2002
Odor Issues
26. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below ❑ Yes ❑ No
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes ® No
28. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt, ❑ Yes ® No
roads, building structure, and/or public property)
29. Is the land application spray system intake not located near the liquid surface of the lagoon? ❑ Yes ❑ No
30. Were any major maintenance problems with the ventilation fan(s) noted? (i.e. broken fan belts, missing or
or broken fan blade(s), inoperable shutters, etc.) ❑ Yes ® No
31. Do the animals feed storage bins fail to have appropriate cover? ❑ Yes ❑ No
32. Do the flush tanks lack a submerged fill pipe or a permanent/temporary cover? ❑ Yes ❑ No
has 72 total confined cattle in the barns, including calves, heifers, etc. Only 40 milk cows were noted. 1 -I
that were left blank do not pertain to this facility at this time.
O5103101

(Type of Visit— u uompuance inspection u uperauon Heview u Lagoon tvaivauon I
Reason for Visit O Routine O Complaint p Follow up O Emergency Notification O Other ❑ Denied Access
Facility Number 85 7 (late of Visit: 220/2001 Time: 1400
0 Not Operational Below Threshold
Permitted S Certified E3 Conditionally Certified ❑ Registered Date Last Operated or Above Threshold: 9&1.19.97 .......
Farm Name: Plaxaslence.FArto.......................................................................................... County: st�es................................................. .W.SRO.......
3
OwnerName:.Th.Qmm.................................. 5.11tur .......................................................... Phone No;�it.K-42�7.-5.7.9A.... .........................................
Mailing Address: 1IS.5..11»'y..7.7U....................................................................................... Piutc.11011 NC.......................................................... 27.9.42 ..............
Facility Contact::1b.mu.Shore................................................Title..................................... Phone No:. j 33� 4 a-793oq
Onsite Representative: Thoximi.Shore........................................................................... Integrator: ................................ _..................... .............................. ..
Certified Operatorjb9i[ s................................. Shot'.e................................................. Operator Certification Number: 21.439.............................
Location of Farm:
1 miles from Madison NC. From WSRO • US 311 North to Hwy 772. Turn left onto 772. Go 1 and 1/4 miles to my mail box A
with name on top). Turn left directly across road from the mailbox onto private lane and continue to end of the lane.
❑ Swine ❑ Poultry ® Cattle ❑ Horse Latitude 36 19 =IF 20 Longitude F 80 • 04 IS
H"
A
Oil
De91 n CurrentTd
B
Ca acit Mopulation
.A..g��
Dest n .l Current
Poultry "" Ca acit P,o ulation ` Cattle
Design Current"•, ,
Ca actf .. P,o ulation:,
❑ Wean to Feeder
❑ Layer
®Dairy
240 42
E
❑ Feeder to Finish:
❑ Non -Layer
I❑Non-Dairy
❑ Farrow to Wean
❑Other
Total Design Capacity
Total SSI W
""- ,�a ,'?'•
' ' ' ` '
240
{
336,000
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
Number of Lagoons 0 ❑ Subsurface Drains Present ❑ Lagoon Area ❑ Spray Field Area
Holding Ponds /Solid Traps 0 ❑ No Liquid Waste Management System
Discharges & Stream Impacts
1. 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 Slate? (It' yes, notify DWQ) ❑ Yes ® No
c. If discharge is observed, what is the estimated Flow in gal/min? < I gpm
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 adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes ® No
01/01/01 Continued
y39'�

Facility Number: 85-7 Date of Inspection 2/20/2001 Waste Collection & Treatment
4.
Is storage capacity (freeboard plus storm storage) less than adequate? ® Spillway
❑ Yes
® No
Structure I Structure 2 Structure 3 Structure 4 Structure 5
Structure 6
Identifier: ......k A$.tS.Rnmd...... ................................... .................................... ................................... ......................................................................
Freeboard(inches): ............... �.Q............... .................................... ................................... ..................................... .................................... ....................................
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
closure plan?
❑ Yes
® No
(If any of questions 4-6 was answered yes, and the situation poses an
immediate public health or environmental threat, notify DWQ)
7.
Do any of the structures need maintenance/improvement?
❑ Yes
® 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
elevation markings?
® Yes
❑ No
Waste
Application
10.
Are there any buffers that need maintenance/improvement?
❑ Yes
❑ No
II.
Is there evidence of over application? ❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload
❑ Yes
❑ No
12.
Crop type
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?
❑ Yes
® No
b) Does the facility need a wettable acre determination?
❑ Yes
® No
c) This facility is pended for a wettable acre determination?
❑ Yes
® No
15.
Does the receiving crop need improvement?
❑ Yes
❑ No
16.
Is there a lack of adequate waste application equipment?
❑ Yes
® No
17.
Are rock outcrops present?
❑ Yes
❑ No
18.
Is there a water supply well within 250 feet of the sprayfield boundary? ❑ Unknown
❑ Yes
❑ No
❑ On -site ❑ Off -site
Required
Records Sc Documents
19.
Fail to have Certificate of Coverage & General Permit or other Permit readily available?
❑ Yes
❑ No
20.
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
21.
Does record keeping need improvement? (ie/ irrigation, freeboard, waste analysis & soil sample reports)
❑ Yes
❑ No
22.
Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
® No
23.
Did the facility fail to have a actively certified operator in charge?
❑ Yes
❑ No
24.
Fail to notify regional DWQ of emergency situations as required by General Permit?
(ie/ discharge, freeboard problems, over application)
❑ Yes
® No
25.
Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes
® No
26.
Does facility require a follow-up visit by same agency?
❑ Yes
® No
27.
Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
❑ No
Odor Issues
28.
Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below
® Yes
❑ No
liquid level of lagoon or storage pond with no agitation'?
29.
Are there any dead animals not disposed of properly within 24 hours?
❑ Yes
® No
01/01/01
Continued

Farjlily Number: 85-7 1 D•� of Inspection 2/20/2001
•30. Is there any evidence of wind drift du0land application'? (i.e. residue on neighboring vegetation, asphalt
roads, building structure, and/or public property)
31. Is the land application spray system intake not located near the liquid surface of the lagoon?
32. Were any major maintenance problems with the ventilation fan(s) noted? (i.e. broken fan belts, missing or
or broken fan blade(s), inoperable shutters, etc.)
33. Do the animals feed storage bins fail to have appropriate cover?
34. Do the Flush tanks lack a submerged fill pipe or a permanent/temporary cover?
Printed on: 2/21/2001
❑ Yes ❑ No
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
❑ Yes ❑ No
113 No violations or deficiencies were noted during this visit. You will receive no further correspondence about this visit.
of
a ua d ❑ Field Copy ® Final Notes
0
lidsurprise/drop-in inspection on this facility to just check liquid level in waste pond. This facility is off the inspection list but it
be a good idea to just check the waste level each year.
.hile walking around the farm, a gray water discharge of washing machine and sink water was discovered coming from the mobile
home residence on the farm. Discharge had not reached waters of the State. The owner stated that his septic system wouldn't handle it
so he piped it out to the ground (see photos in DWQ file). Referred violation to Jim Oakley with Stokes County Environmental Health
on 02/20/01.
Reviewer/inspector Name Melissa R sebrodc
Reviewer/Inspector Signature:- Date: oz Q
01/01/01

t
�
\ 'K
41
f L
z v
A+
xl;' ,
AA
'
(I Pow
q a
f t r S it
Yl
y —
I
IL
x
-a
-
IT 1.4
' i ��

.„ `q-.q..�,� t ♦ :. I } A ��• � k� F ,� t r :.. � � **#p'. x#e +" k°' a � � �t tf• � "5 � � 1 "'pq5 ! .f t /..
_ -i ) " * q4 r I� r♦+� 3x «y5�} Ja + t"' • F X Jti p � { �:. / i t - 'K-d '� kl
i, ♦ • , .1 `,• `�j. fo'{` i,, .f fy. q *$� � $a`1 + o-t „5
i . 4 i
`*Jy. i t ♦1'.y yT ti t,i .,4�• (� ,. �S? {+. x • f :: g,�, t,� e k t \ t µ ' �. —•y
.��, ♦ ; f t ' S4 "" � p<�4� 4� sd Y r Rf i't"` °�` i �, �� 3�'", , ' ��! t •R° } �. %
x t t fit' . � � � a i p s .� r�. •x � ': � •
e ~ t ltdt r `, 'i . ^,Ji
r
ii .®.0 Ji 9' I , f ♦ S "t �.\. i .,. �J y 1 ^ .
#. r i�i
I a ar",• ♦ r .!, ! J i,�,. ", k-Ri«,ki '.rpA t'�`q.1hA. If
tA
tF..7i ; .\
' 1 t��-„+ j( tx f "fit • t,. R e x_s`.. � � � d. v f , �a
+ .�,/• 1.. � tR+ ± �iyj � � .a r �, �` �+. ga.S't• }�tR � " f'• tt::/ 's
tt * 4
fe `�'"r �kL' �• i�[%��Rjr'}, �'[,- r d a.y y� ,� +'�.#,Y r a ♦h.ir. }.•s i �*�"q'«4
24u]p�#°q
c .r � -) � � f Ma w*�!" �..: i 'F st �! « •, r. � �•�'i � ?i \ , ! •' •'(�. t.
la \' w \f�i !•.' ' y, Atltk'S¢
# ♦ «d""� � i� . k� . � i k i t aX '�� q� ♦`' � *r t �'` S 3.i,'• ' ��i. • '
74
ik
it
f�
-� ��+. �. >i ,} ,�; 'ri � � � r q �♦q$., "� s �` ! r•'� r 1�. • " 4 " f �*,i �i
♦ • Y r .., d � .. " � ! '"� p� i r• +t �ay'"t K �..ke ��•. ..'
y �,' X • t { p !,w»:i^� "�. +..� � k' a R "� 1 �� • fr ,k s , J
' ( ,� p♦r ].qI•�#�� ` .5 }� 1#�..`*' "'r' _� . 4 �#ih �� ilk
` ,., . .. r ♦-i ?�1."jtTK�fji t` �". ),i x. \„ : �y4 e
T _ ei` i 4y e.. fi�'Fif ♦t.v,l. �.,� p `
y 4 1
et
q>
,,,ppp t •''.
f �1 I r�` t .,,� 'Y + � � t� -., ; tit �. t ! , $ •� t ,: }
l
q �lf• " � i"` t Gt ��f' g s t p�H�"f
rt (f Ayq
✓ .�. ' V 1 � e �. 4 t 5 ' { f Y.. yi
r .
# ,
1.P ♦1 1 �e ri...
Y' Xj't� i}t� �.; '�� '++�• � +: tx .µa .'�x�.�i' q't�`���'R'��s'�
r 7
# , " r r F a • � . A'�i -ri.\�'i ar « ! W.
A
tp` ♦. 1 X! %f rl} fir
r
• it `� ��� : "� ♦ ak�`A

,k
} �• �"' Ott
1 OT
M 1
,
}
IAL .
Ra- �

Facility Number 85 7 tale °f Visit: 9/20/2000 lime: 13:00 Printed mi: 2/15/2001
0 Not Operational 0 Below Threshold
■ Permitted N Certified E3 Conditionally Certified Q Registered Dale Last Operated or Above Threshold: .........................
Farm Name: PrO.Y.Id1C lularim......................................................................................... County: SIAP5 ................................................ W. S.RQ........
OwnerName: JIjf? W5.................................. SitQre........................................................... Phone No: 910.-.427.-5.79.8 ..........................................................
FacilityContact: ................................................................................... Title:................................................................ Phone No:...................................................
Mailing Address: RI.1,.iQx.SS.-1lA.........t%..�?5 .....%t.W l........................ PIt1e.HAlt.l1'.0.......................................... I ............ :. 2.7.9.42 .............
OnsileRepresenta(ive:.Tb.Q.MM..Sbp..r.g............................................................................ Integrator:......................................................................................
Certified Operator:.Th.QM0fi..1.C............................. Shore.1r,.......................................... Operator Certification Number:21.43Q
.............................
Location of Farm:
r miles from Madison NC. From WSRO - US 311 North to Hwy 772. Turn left onto 772. Go I and 1/4 miles to my mail box A
with name on top). Turn left directly across road from the mailbox onto private lane and continue to end of the lane.
[I Swine [I Poultry ® Cattle ❑ Horse Latitude 36 • 21 ' 20 Longitude 80 • 04 15
„ a `Detgn� i iCurr�ent S,xDestgn Gu'rrent� Design Current ,
Swine a' "+ Ca acit rP,o mlation�u. Poult , t� fix "Cattle 4tr" ' `
ry Ga actt P,o ulahon y,.y„ `' Gii actf , Pd ulationt.
#j ❑ Wean to Feeder ❑Layer ® Dairy 240 51
❑ Feeder to Finish ; ❑Non -Layer ❑ Non Dairy
❑
Farrow to Wean a
❑ Other
A- ❑ Farrow to Feeder +i
❑Farrow to Finish Totapl Design Capactty 240
❑Gilts 8 K`� ,.r`,
+q'C ❑Boars °' " � 1 SSLW 336,000:J J
F�Ijl„Number of Lagoons 1� ❑ Subsurface Drains Present ❑ Lagoon Area ❑ Spray Field Area
Holding Ponds /Solid Traps ❑ No Liquid Waste Management System;
Discharges IN, Stream Im • cts
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 adverse 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 I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: .......................................................................................................................................................................................................................
Freeboard (inches): 36
5100 Continued on back

Facility Number: SS-7 db Date of Inspcetiun 9/20/21100 Printed on: 2/15/2001 !
5. Are there any immediate threats to the to my of any of the structures observed? (ie/ tree., vere erosion, []Yes ® No
seepage,. etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or
closure plan? ❑ Yes ® No
(If any of questions 4-6 was answered yes, and the situation poses an
immediate public health or environmental threat, notify DWQ)
7. Do any of the structures need maintenance/improvement? ® Yes ❑ 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
elevation markings?
❑ Yes
® No
Waste Application
10.
Are there any buffers that need maintenance/improvement?
❑ Yes
® No
11.
Is there evidence of over application'? ❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload
❑ Yes
® No
12.
Crop type Fescue (Graze)
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?
❑ Yes
❑ No
b) Does the facility need a wettable acre determination?
❑ Yes
❑ No
c) This facility is pended for a wettable acre determination?
❑ Yes
❑ No
15.
Does the receiving crop need improvement?
❑ Yes
® No
16.
Is there a lack of adequate waste application equipment?
❑ Yes
® No
Reouired Records &. Documents
17.
Fail to have Certificate of Coverage & General Permit readily available?
❑ Yes
® No
18.
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
19.
Does record keeping need improvement? (ie/ irrigation, freeboard, waste analysis & soil sample reports)
® Yes
❑ No
20.
Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
® No
21.
Did the facility fail to have a actively certified operator in charge?
❑ Yes
® No
22.
Fail to notify regional DWQ of emergency situations as required by General Permit?
(ie/ discharge, freeboard problems, over application)
❑ Yes
® No
23.
Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes
® No
24.
Does facility require a follow-up visit by same agency?
❑ Yes
® No
25.
Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
® No
7777
No vioiatioris:or d,efciencie's were noted :during this; vi$it: ;Ytiu:'Will receive #to•ftirth'er
I
.
correspondence. tibb this visit... ... ... .. .
Keep veegetation height at 18" or less to allow for easy vissual inspection. Can spray weeds, Keep height down to start pumping I
19. Hsa not hauled since last year. Can pump thru 11/30 on Fescue . Need to keep weekly freeboard records once permitted.. Pipe is
set for 2' freeboard.
will serve as a removal confirmation.
Reviewer/Inspector Name .Margaret Okeefe
Reviewer/Inspector Signature: Date: 5100

-Face ity Number: 85-7 of Inspection 9/20/2000 • Printed on: 2/15/2001
l dnr Iss, lies
26. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below ❑ Yes ❑ No
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes ® No
28.
Is there any evidence of wind drift during land application'? (i.e. residue on neighboring vegetation, asphalt,
❑ Yes
® No
roads, building structure, and/or public property)
29.
Is the land application spray system intake not located near the liquid surface of the lagoon'?
❑ Yes
® No
30.
Were any major maintenance problems with the ventilation fan(s) noted'? (i.e. broken fan belts, missing or
or broken fan blade(s), inoperable shutters, etc.)
❑ Yes
® No
31.
Do the animals feed storage bins fail to have appropriate cover?
❑ Yes
® No
32.
Do the flush tanks lack a submerged fill pipe or a permanent/temporary cover?
❑ Yes
❑ No
" [bona •timmen an r raw ngs:
5100
5100

Routine
of
Facility Number Date of Inspection
Time of Inspection SS 24 hr. (hh:mm)
Permitted ❑ Certified E3 Conditionally Certified 0 Registered Not O crational Date Last Operated: ..........................
'7� s C1
Farm Name: .....Y..EAYIUCA:C.'.-. ....... FaI.:. Farm. ........................................... County:..........s T1..�.I�e'.5 ......................7........p...............
Owner Name:...a...4......0.ryo ...... ......t..h.fa.).^.......................................... Phone No: ... 33.6 ...... �.. ...:_ ..1... ..!!.
Facility Contact: T6rnO s............S.hh.r...... Title: ................................................................ Phone No:...................................................
Mailing Address: ......... �...� S�" f.......................................o V I n czLan.4 - PLY1.Q ... G� ...�..�.1 NC- a % Q �Z
t.�./.�...n... < C.............................................. ..........................
OnsiteRepresentative: r.a..1.oz......C....Shi t.................................... Integrator:.........................................................................................
Certified Operator: ,,,,Q:,,,,,,,,,,,sT���,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, Operator Certification Number: ,,,,,1,,,!,,9,
... ............
Location of Farm:
Latitude ®0®' 10 Longitude ®•®'®"
,.
D tg�
�'
�!
uuklraentn7
Da esat P4 u
�$❑w�
ti�CaacPopulation our
„C
at� tlre�
atetP1oC
,,Cme
.0cit PoCurlfaetniotn
.`Wean to Feeder
Ott
A': ❑ Feeder to Finish
''
f! i ❑ Farrow to Wean
❑ Other ... ,
_? ❑Farrow to Feeder
Farrow to Finish
TotaPDestgti";Ca`pacity; i
5
❑ Gilts�
31�3❑ Boars1.
t.
r
�;Totel SSLW i�:
.
33 tQ
11.
, t��'
J.
Number of Lagoons
;,
_� r
❑Subsurface
Drains Present
❑Lagoon Area
❑Spray Fteld Area tg
1 t
Holdin Ponds /Solid Tra s
: g: o p,
t
❑ No Liquid Waste Management System
t + 1 , a, tr ,
r
t
❑ Layer
Dairy
a1 S Q
❑ Non -Layer
�I ❑Non -Dairy
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made?
b. II' discharge is observed, did it reach Water of the State? (If yes, notify DWQ)
c. If discharge is observed, what is the estimated flow in gal/min?
d. Does discharge bypass a lagoon system'? (If yes, notify DWQ)
2. Is there evidence of 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?
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? Spillway
Structure I Structure 2 Structure 3 Structure 4 Structure 5
Identifier:
11
Freeboard (inches): .............................
❑ Yes XNo
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes No
❑ Yes No
❑Yes )<No
Structure 6
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, ❑Yes it7�No
seepage, etc.) �"'
3/23/99 Continued on back

Facilily'Number: S —0--] •te of Inspection
6. Are there structures on -site which Aproperly addressed and/or managed through a waste management or
closure plan?
(If any of questions 4-6 was answered yes, and the situation poses an
immediate public health or environmental threat, notify DWQ)
7. Do any of the structures need maintenance/improvement?"
8. Does any part of the waste management system other than waste structures require maintenance/improvement?
9. Do any stuclures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings?
Waste Application
10. Are there any buffers that need maintenance/improvement?
11. Is there evidence of over application? ❑ Excessive Ponding ❑ PAN
12. Crop type Fese u e -,,)as-{vr-e_LG r-au_.
13. Do the receiving crops differ with
IxYes ❑ No
❑ Yes [XNo
XYes ❑ No
❑ Yes kNo
❑ Yes ,<No
Certified Animal Waste Management Plan (CAWMP)? ❑ Yes A 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?
Required Records & Document%
17. Fail to have Certificate of Coverage & General Permit read ly available?
18. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.)
19. Does record keeping need improvement? (ie/ irrigation, freeboard, waste analysis & soil sample reports)
20. Is facility not in compliance with any applicable setback criteria in effect at the time of design?
21. Did the facility fail to have a actively certified operator in charge'?
22. Fail to notify regional DWQ of emergency situations as required by General Permit?
(ie/ discharge, freeboard problems, over application)
23. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
24. Does facility require a follow-up visit by same agency?
25. Were any additional problems noted which cause noncompliance of the Certified AWMP?
0' N4 ..* l'aiiotis oi-• dgFciencieg �v$rb pgted.O(wing 4his;visit.' • Y;oU ;wiii•QO0iye tjo; fui•thtir
ctir'resnotidence. about: this :visit: ::::::::......::::::::::::::::::: :
RFescue, graze Fe-61— IV 30 Pram
Cbrn 51 to ge Rfp ri I I — S u 1t�3o
Sorgh">rn R� pril I— .Tuly 30
-1. Ntad i I & A ea4le_ OfT d am .
Re S e- PA P-3-
Reviewer/Inspector Name
Reviewer/Inspector Signai
ICJ uP
❑ Yes No
❑ Yes ,�/No
pa ❑ Yes No
❑ Yes VNO
❑ Yes 5Io
❑ Yes DU No
❑ Yes Val No
*Yes /�❑[ No
❑ Yes Q} No
❑ Yes o
❑ Yes No
❑ Yes No
❑ Yes No
❑ Yes A No
dam needs -fa b - FePal
IQUId rnari-� nrh<
eadl=� be b P05.h -csf ?
�M
Date:

Facility Number: �e of Inspection •
Odor Issues
26. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below ^- 94e&4 , Q
liquid level of lagoon or storage pond with no agitation? OM 1 -
27. Are there any dead animals not disposed of properly within 24 hours?
28. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt,
roads, building structure, and/or public property)
29. Is the land application spray system intake not located near the liquid surface of the lagoon?
30. Were any major maintenance problems with the ventilation fan(s) noted? (i.e. broken fan belts, missing or
or broken fan blade(s), inoperable shutters, etc.)
31. Do the animals feed storage bins fail to have appropriate cover?
32. Do the flush tanks lack a submerged fill pipe or a permanent/temporary cover? om 17-a 006
❑ Yes XNo
❑ Yes AIo
❑ Yes 1/10
❑ Yes No
❑ Yes I
'Ale
Meyc. li$v)d m &rIe i5 1' above, sPi ll Per
Qer-a�i�
�e �5 5,"above, \jr/a q W. s+or� �
ILOUP
No Sol +e5� reCorc�S �Fo / 149q — w v
LoJ 'e 50mwIeoJam <g/y 91./�sf�
o r oo116., i oh record -or e2000. SLUrZ I on� �
01. 1999 Card loCafed —P� ?w.loeked lafaa', as we -II
19 o N,aed --( reeorc� wreiC ( ro:ins Free r&l®tA_

Je Routine 0 Complaint 0 Follow-up of DNVQ inspection 0 Follow-up of DSWC review 0 01her
I Facility Number 85 7 [l)a1c ul' Inspection 7/13/99
"Time. of Inspection 17:00 24 hr. (hh:mm)
Permitted ® Certified, Q Conditionally Certified [3 Registered Not O errlional Date Last Operated: ..........................
Form Name: >'forixlexlt:.e..Fartp.......................................................................................... County: S.tplces................................................ FYS.ItQ........
ONnerName: Tltotttas.................................. shurg ........................................................... Phone No: 910427:579.8 ...........................................................
Facility Contact:
Title:
Phone No:
MailingAddress: lit.JIox.S,S-H.................................................................................... flneXA1012 ......................................................... 2.7.0.42 ..............
Onsite Representative: a'.t1U11aaS.$CIA.Cf............................................................................ Integrator:
Certified Operator:.ThjQ.MM..1.C............................. ShQ.re rB......................................... Operator Certification Number:2J.439 .............................
Location of Farm:
Latitude 36 • =1 F 20 Longitude = • =1 15 I•
"d Design
Sw_ tneit ' t
Giffe'nt
Destgn ,_Cur" nt b, a Destgn; Current
` PoultnY Ca la on Cattle " '
E ;
Capacit
❑ Wean to Feeder
P,o tula Jon
acit Prop �uv Ca ractt „ Po wlation ..
❑Layer ®Dairy 240 3`
h
❑ Feeder to Finish
❑Non -Layer ❑Non -Dairy f'
❑ Farrow to Wean
�.
❑Farrow to Feeder
❑Other :e ; { ,A S .. a r + ' ,` v.
�
F
❑ Farrow to Finish
l)R Total D�essiign Capa`crty, 240 t
wv + ,,
w To�ta�l SSLW 336.000 ,
❑ Gilts
❑ Boars
Number of Lagoons 0
❑ Subsurface Drains Present ❑ Lagoon Area ❑Spray Field Arca
Holding Ponds /Solid Traps
❑ No Liyuid Waste Management System
Discharges X Stream Impacts
I. Is any discharge observed from any part of the operation?
Discharge originated au ❑ Lagoon ❑ Spray Field ❑ Other
it. If discharge is observed, was the conveyance man-made'? '
b. It' discharge is observed, did it reach Water of the State'? (If yes, notify DWQ)
c. If discharge is observed, what is the estimated flow in gal/min?
d. Does discharge bypass a lagoon system? (if yes, notify DWQ)
2. Is there evidence of 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?
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? 0 Spillway
Structure I Structure 2 Structure 3 Structure 4 Structure 5
Identifier:
Freeboard (inches): ................7.2................
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
Structure 6
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, ❑ Yes ® No
seepage, etc.)
3/23/99 Continued on back
Printed on 5/9/2000

Facility Number: 85-7 • W Inspection
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or
closure plan?
(If any of questions 4.6 was answered yes, and the situation poses an
immediate public health or environmental threat, notify DWQ)
7. Do any of the structures need maintenance/improvement?
8. Does any part of the waste management system other than waste structures require maintenance/improvement?
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings?
Waste Application
10. Are there any buffers that need maintenance/improvement?
7/13/99
❑ Yes
® No
® Yes
❑ No
❑ Yes
® No
❑ Yes
® No
❑ Yes
® No
11. Is there evidence of over application? ❑ Excessive Ponding ❑ PAN ❑ Yes ❑ No
12. Crop type Fescue (Graze)
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? ❑ Yes ® No
b) Does the facility need a wettable acre determination? ❑ Yes ® No
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?
Required Records & Documents
17. Fail to have Certificate of Coverage & General Permit readily available?
18. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.)
19. Does record keeping need improvement? (ie/ irrigation, freeboard, waste analysis & soil sample reports)
20. Is facility not in compliance with any applicable setback criteria in effect at the time of design?
21. Did the facility fail to have a actively certified operator in charge?
22. Fail to notify regional DWQ of emergency situations as required by General Permit?
(ie/ discharge, freeboard problems, over application)
23. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
24. Does facility require a follow-up visit by same agency?
25. Were any additional problems noted which cause noncompliance of the Certified AWMP?
: No violatigns:or deficiencies were :noted ;during this; visit. ;You:will receive uo fu'rth'er
. corresuotidence. about this vtstt..
comments efe—ETRUNIT—tFUHURY,E rpliiin eny YE ans ens and%or any recommenda`tlons or eny other Comm
IS drawin of facility to ette explain situations. use additional pages as necessary
8. Need to get nitrogen balance and appliation windows on/in WUP.
9. Need a soil test. Make sure that a waste sample is pulled within 60 days of any application.
Reviewer/Inspector Name Margaret O'Keefe Ken Martin
Reviewer/Inspector Signature: Date:
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
® Yes ❑ No
® Yes ❑ No
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
Printed on 5/9/2000 /
I

Facility Number:' 85-7 �d'Inspectinn 7/13/99 •
Odor Issues
26. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below ❑ Yes ® No
liquid level of lagoon or storage pond with no agitation?
27.
Are there any dead animals not disposed of properly within 24 hours?
❑ Yes
® No
28.
Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt,
❑ Yes
® No
roads, building structure, and/or public property)
29.
Is the land application spray system intake not located near the liquid surface of the lagoon?
❑ Yes
® No
30.
Were any major maintenance problems with the ventilation fan(s) noted? (i.e. broken fan belts, missing or
or broken fan blade(s), inoperable shutters, etc.)
❑ Yes
®No
31.
Do the animals feed storage bins fail to have appropriate cover?
❑ Yes
® No
32.
Do the flush tanks lack a submerged fill pipe or a permanent/temporary cover?
❑ Yes
® No
At
Printed on 5/9/2000

19 Routine O Complaint O Follow-up of DWQ inspection O Follow-up of DSWC review O Other
Facility Number 85 07 Date of Inspection 3/18/99
Time of Inspection 14:00 24 hr. (hh:mm)
0 Registered ® Certified 0 Applied for Permit 0 Permitted 10 Not Operational I Date Last Operated:
Farm Name: ProxkieacoXAm.......................................................................................... County: Stakes, ................................................ ..SRO........
OwnerName: Thomas .................................. shom ........................................................... Phone No: 9.10. 42..M79.8...........................................................
FacilityContact: .............................................................................. Title:................................................................ Phone No:...................................................
MailingAddress: Rt.I B.axSS-M..................................................................................... Pine.Hall.N.0 ......................................................... 77.0.42 .............
Onsite Representative: Th.aram.Sholle............................................................................ Integrator:......................................................................................
Certified Operator: Tlwmas.K............................ wwreAr .......................................... Operator Certification Number:,2].93.Q.............................
Location of Farm:
Latitude 367• 21 20 Longitude 80 • 04 15
General
I . Are there any buffers that need maintenance/improvement?
© Yes
® No
2. Is any discharge observed from any part of the operation?
© Yes
® No
Discharge originated at: [j Lagoon [J Spray Field ❑ Other
a. If discharge is observed, was tie conveyance man-made?
0 Yes
0 No
b. If discharge is observed, dirt it reach Surface Water'? (If yes, notify DWQ)
❑ Yes
❑ No
c. If discharge is observed, what is die estimated flow in gal/mini?
d. Does discharge bypass a lagoon system? (If yes, notify DWQ)
© Yes
© No
3. Is there evidence of past discharge from any part of die operation?
❑ Yes
S No
4. Were there any adverse impacts to the waters of the State other than from a discharge?
❑ Yes
® No
5. Does any part of the waste management system (other than lagoons/Iholding ponds) require
❑ Yes
No
maintenance/iniprovenient?
6. Is facility not in compliance with any applicable setback criteria in effect at tie time of design'?
Yes
No
7. Did the facility fail to have a certified operator in responsible charge?
❑ Yes
® No
7/25/97

Facility P,iumber: 85-07 Date spection 3/18/99
S. Are there lagoons or storage ponds on site Bich need to be properly closed? ❑ Yes ® No
Structures (Laeoons.Holdine Ponds, Flush Pits. etc.)
9. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Yes ❑ No
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
.......................................................................................................................................................................................................................
Freeboard(ft):........................................................................................................... .........................................................................................................
10. Is seepage observed from any of the structures? ❑ Yes ® No
11. Is erosion, or any other threats to the integrity of any of the structures observed'? ❑ Yes ® No
12.
Do any of the structures need maintenance/improvement?
❑ Yes
® No
(If any of questions 9-12 was answered yes, and the situation poses an
Immediate public health or environmental threat, notify DWQ)
13.
Do any of the structures lack adequate minimum or maximum liquid level markers?
❑ Yes
® No
Waste Application
14.
Is there physical evidence of over application'?
❑ Yes
® No
(If in excess of WMP, or runoff entering waters of the State, notify, DWQ)
15.
Crop type....................................................................................................................................................................................................................................
16.
Do the receiving crops differ with those designated in the Animal Waste Management Plan (AWMP)?
❑ Yes
Ig No
17.
Does the facility have a lack of adequate acreage for land application?
❑ Yes
® No
18.
Does the receiving crop need improvement'?
❑ Yes
® No
19.
Is there a lack of available waste application equipment?
❑ Yes
® No
20.
Does facility require a follow-up visit by sane agency?
❑ Yes
H No
21.
Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes
® No
22.
Does record keeping need improvement?
❑ Yes
H No
For Certified or Permitted Facilities Only
23.
Does the facility fail to have a copy of the Animal Waste Management Plat readily available?
❑ Yes
® No
24.
Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
No
25.
Were any additional problems noted which cause noncompliance of the Permit?
❑ Yes
M No
No. olatibtlsor'd'efitieiteies•wete'goted'duYapgthis•Visit.;Y.ou•w111'rWeiVe,nb'falr'ther.
corres»oudence iho W ihis. visit.• . ............................ .
Holding pond has approximately 1 1 /2 ft. of freeboard - needs pumnping. Equipment has been purchased to ptunp holding pond
Reviewer/Inspector Name
Date:

Division of Soil W Water Conservation 0 Other
Division of Water Quality
Facility Number Date of Inspection Q`jQ3
�
Time of Inspection ©24 hr.(hh:mm)
E3 Registered Certified E3 Applied for Permit 0 Permitted [3 Not Operational I Date Last Operated:
Farm Name:.....P�� ? V.I 2n1C�:.`....P..'/. je W!.................................................. County:...../YR.t�s........................................................
Owner Name:.... L..'�..1. q' 'S/L°L............................................................ Phone No'o h� � 2—% " S % c! c�
Facility Contact: r' � / ° Qpm................ Title: ,. t .(l!.N e.(L................................ Phone No 3 (.Z% S % /�.8
........................ ......... ................. ./.........1.................................
Mailing Address: ................................. ............ ...��ss..�...... ...` ' .. T ``^ ° V �.".'�..r:. •. 0�1_
......... .
OnsiteRepresentative�� tyf. ._ S%ve/L¢.................................................... Integrator:......................................................................................
Certified Operator:.....L..z!.'.1.42 ..../L� ..................................................... Operator Certification Number ..........................................
Location of Farm: tizo u 3 /1IVD ,0' i V , ti 7 -7.,1- . <14,1 /e(>Cf d Ilia L" 272
ti
Latitude ®• 0' ®" Longitude =• D®' ©"
!UJL
`w ," ' v"
Design ` Current,
Design ; Current ' Design Current '
Capacity .Population-
, Poultry Capacity,�Population Cattle ', '� , Capacity;'Population
Wean to Feeder
Farrow to Wean
❑
[I Feeder to Finish
❑
❑ Farrow to Feeder
El Farrow [o Finish
❑ Gilts
❑ Boars
General
1. Are there any buffers that need maintenance/improvement? ❑ Yes Xj No
2. Is any discharge observed from any part of the operation? ❑ Yes *o
Discharge originated at: El Lagoon [I Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made? ❑ Yes [I No
b. If discharge is observed, did it reach Surface Water? (If yes, notify DWQ) ❑ Yes El No
c. If discharge is observed, what is the estimated Flow in gat/min?
d. Does discharge bypass a lagoon system? (If yes, notify DWQ) [I Yes [I No
3. Is there evidence of past discharge from any part of the operation? El Yes K,No
4. Were there any adverse impacts to the waters of the State other than from a discharge? ❑ Yes �I o
5. Does any part of the waste management system (other than lagoons/holding ponds) require ❑ Yes �No
maintenance/improvement? El,
6. Is facility not in compliance with any applicable setback criteria in effect at the time of design? Yes dNo
7. Did the facility fail to have a certified operator in responsible charge? ❑ Yes �No
7/25/97
General
1. Are there any buffers that need maintenance/improvement? ❑ Yes Xj No
2. Is any discharge observed from any part of the operation? ❑ Yes *o
Discharge originated at: El Lagoon [I Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made? ❑ Yes [I No
b. If discharge is observed, did it reach Surface Water? (If yes, notify DWQ) ❑ Yes El No
c. If discharge is observed, what is the estimated Flow in gat/min?
d. Does discharge bypass a lagoon system? (If yes, notify DWQ) [I Yes [I No
3. Is there evidence of past discharge from any part of the operation? El Yes K,No
4. Were there any adverse impacts to the waters of the State other than from a discharge? ❑ Yes �I o
5. Does any part of the waste management system (other than lagoons/holding ponds) require ❑ Yes �No
maintenance/improvement? El,
6. Is facility not in compliance with any applicable setback criteria in effect at the time of design? Yes dNo
7. Did the facility fail to have a certified operator in responsible charge? ❑ Yes �No
7/25/97

Facility-Ndmber: 8 — 0 • •
8. Are there lagoons or storage ponds on site which need to be properly closed?
StructureslLaeoons.tlolding Ponds, Flush Pits. etc.)
9. Wstorage capacity (freeboard plus storm storage) less than adequate?
Structure I Structure 2 Structure 3 Structure 4
Identifier:
Freeboard (f):.......1...................................................
10. Is, seepage observed from any of the structures?
11. Is erosion, or any other threats to the integrity of any of the structures observed?
12. Do any of the structures need maintenance/improvement?
(If any of questions 9-12 was answered yes, and the situation poses
an immediate public health or environmental threat, notify DWQ)
❑ Yes kNo
❑ Yes ❑ No
Structure 5 Structure 6
❑ Yes X No
❑ Yes I�No
❑ Yes I�No
13. Do any of the structures lack adequate minimum or maximum liquid level markers? ❑ Yes XNo
Waste Application rC0 (((-
14. Is there physical evidence of over application? �5 F (�q �i C(Jiw�J p R io(L �V ) 0 ❑Yes No
(If in excess off WMP, or runoff entering waters of the Staten, Ltlify DWQ)
15. Crop type UxC?SGkL e
................................................................................................................................................................. k
......................................
16. Do the receiving crops differ with those designated in the Animal Waste Management Plan (AWMP)? ❑ Yes N No
17.
Does the facility have a lack of adequate acreage for land application?
❑ Yes
*0
18.
Does the receiving crop need improvement?
❑ Yes
No
19.
n
Is there a lack of available waste application equipment?NF11Ctv-ib- 1.Npr+urge-
❑Yes
.$No
20.
Does facility require a follow-up visit by same agency?it/+S
❑ Yes
P No
21.
Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes
ifNo
22.
Does record keeping need improvement?
❑ Yes
gjNo
For Certified or Permitted Facilities Only
23.
Does the facility fail to have a copy of the Animal Waste Management Plan readily available?
❑ Yes
O No
24.
Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
95 No
25.
Were any additional problems noted which cause noncompliance of the Permit?
❑ Yes
X,No
No.violtitioiwordt:Ficiencieawe.renotedduriug this:visit. You.wil}'receive no further
etirrespoitdetti:e tib'ouf fhis;visit:: ; : ; : - ; • ; • ; • ; • ::: , , . . . . . . . .. . . . . .. .
7/25/97
Reviewer/Inspector Name
Reviewer/Inspector Signature:

DSWC Aniniff Feedlot Operation Review
x
'
DWQ Animal Feedlot Operation Site Inspection
g
is F
toutine'
O Complaint
O Follow-up ol'DWO inspection O Follow -lip of DSWC review�Ot�heerr
[ijD7mte of Inspection
L2i1tL!"S
Facility Number �$ —�
ie o f Inspection
©24
hr. (hh:mm)
E3 Registered F Certified 0 Applied for Permit [3 Permitted JE3 Not Operational I Date Last Operated:
FarmName:......- e OdJ.CQ21�✓LI .......................................... County:....? �V/,Q.. [..................................................
Owner Name:...'...�..m /tat/fS.......+ J/W R�Q.......................................................... Phone No:. c Svt T L% ^S%7 O
I•~"..C..........)........................................
Facility Contact: �f S47 D �• N� 336 Yz7- S� 48
fp..............(.....................e................ Title:.................. Phone No �.....................
Mailing Address: ........1Q.4......_�.....0........,ram/ s ..............................
Onsite Representative:.....(../ _u. 'i .i......9AA..?w. .....................................
Certified Operator;...% .M s., ...................
................................
Location of Farm: 9w *4 3' ` A r& 4;L
...........I .................... .......................- .......................
Integrator: ......................................................................................
Operator Certification Number;;�_Y.;
.............
Iv . Lez� A& c$l2�_
Latitude ®•E�• `l Longitude ®� �' F7a,7,,,
Swine Capacity Population
❑ Wean to Feeder
❑ Feeder to Finish
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
Number of Lagoons / Holding Ponds
General
Poultry Capacity Population Cattle Capacity Pi
❑ Layer I Kbairy 12V
❑ Non -Layer 1 10 Non -Dairy
❑ Other
Total Design Capacity.
Total SSLW �—
J❑ Subsurface Drains Present JLJ Lagoon Area J❑ Spray Field A
❑ No Liquid Waste Management System
I. Are there any buffers that need maintenance/improvement?
2. Is any discharge observed from any part of the operation'?
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made?
b. I'discharge is observed, did it reach Surface Water? (If ycs. notify DWQ)
c� Itdischan, is observed, what is the estimated flow in gal/min?
d. Does discharge bypass a lagoon system? (It yes, notify DWQ)
3. Is there evidence of past discharge from any part of the operation?
4. Were there any adverse impacts to the waters of the State other than from a discharge?
5. Does any part of the waste management system (other than lagoons/holding ponds) require
maintenance/improvement?
6. Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes '01No
❑ Yes [ 6`0
❑ Yes o
❑ Yes o
❑ Yes No
❑ Yes o
❑ Yes No
❑ Yes 4 No
❑ Yes No
❑ Yes No
Continued on back
7. Did the facility fail to have a certified operator in responsible charge?
7/25/97 sc 9J

Facility Number: 8 — 6 •
Are there lagoons or storage ponds on site which need to be properly closed?
❑ Yes �*o
Structures (Lagoons.Holdine Ponds. Flush Pits. etc.)
9.
Is storage capacity (freeboard plus storm storage) less than adequate?
�.(���
❑ Yes L�, 0
+ Structure I S cture 2 Structure 3 Structure Structure 5
Identifier:
Structure(( 6
�4
e..(.�.t.N.....S...P_D..t.......................................................................
Freeboard(ft):......... �..?.................................................................................................................................. ....................................
....................................
10.
Is seepage observed from any of the structures?
❑ Yes No
11.
is erosion, or any other threats to the integrity of any of the structures observed?
v
❑ Yes t`] No
12.
Do any of the structures need maintenance/improvement?
❑ Yes No
(If any of questions 9-12 was answered yes, and the situation poses
an immediate public health or environmental threat, notify DWQ)
13.
Do any of the structures lack adequate minimum or maximum liquid level markers?
❑ Yes No
Waste Application
14. Is there physical evidence of over application?
❑ Yes �610
(If in excess of WMP, or runoff entering waters of the State, notify DWQ)
15.
Crop type ... 1....P.5+'�L.Pf...... .C..12S?'....... 1,41VA .......................................................................................................................................
16.
Do the receiving crops differ with those designated in the Animal Waste Management Plan (AWMP)?
❑ Yes,,[, No
17.
Does the facility have a lack of adequate acreage for land application?
❑ Yes ICt No
18.
Does the receiving crop need improvement?
❑ Yes] No
19.
Is there a lack of available waste application equipment?
Yes ❑ No
20.
Does facility require a follow-up visit by same agency?
❑ Yes �$jj No
21.
Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes ,)J No
22.
Does record keeping need improvement?
77777T''"'�es ❑ No
For Certified or Permitted Facilities Only
)6
23.
Does the facility fail to have a copy of the Animal Waste Management Plan readily available?
❑ Yes No
24.
Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes JdNo
25.
Were any additional problems noted which cause noncompliance of the Permit?
❑ Yes )6 No
0 • No.violatiohs or deficiencies. were noted during this.visit.:You:yvill receive no ftirthei-
.................
correspotidepee about this:visit:•:: ; ; : ; ' ::: ' :: ; " : ;
�2, h'1tsOle�ce� odILR��te2cQs
Vcl. QiJnJS 5f)D� cvp-s,te / u VO
f t� I AJ �j �D N dC SIW.�^^�(J` D✓'+'�`� .Q R J D 0. V �' W� (.�'^ .' / / F
7/25/97
Reviewer/Inspector Name
Reviewer/Inspector Signature: .�Ua+r� Q - G A-u4ze Date: yQ 090 2

F;
Facility Number
Farm Status: 'A Registered ❑ Applied for Permit
❑ Certified ❑ Permitted
❑ Not Operational Date Last Operated:...,
of
Date of Inspection
Time of Inspection
24 hr. (hh:mm)
Total Time (in fraction of hours
(ex:1.25 for 1 hr 15 min)) Spent on Review
or Insnection !includes travel and nrnressinnl
FarmName: ..................................... . ............................................................... . ...... . ....... County:........5 _!?:.!� _._.................... _....... _..........
Land Owner Name:..1_IA..R.1.}11 .5................ Phone No:..6FA P� �2-X:'..%,TS
Facility Conctact:........1..L.tr?! ....... ....._... Title:._...Ql.!a! ±........... ... Phone No:(
MailingAddress:..... ................ (.SS.)1M. ........_............_.................. ....... _............................................................................. ..........................
Onsite Representative:...1. 0.�'2 a.A...... .�W.a£........................................ Integrator: ........................... _....... _................................................
.
Certified Operator:
Location of Farm:
dr
Latitude s 1,
Operator Certification Number:......
i7z av . L-eAL A0' ®;�, �
Longitude E35—oD• ®, ©11
General
1. Are there any buffers that need maintenance/improvement?
2. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Lagoon ❑ Spray field ❑ Other
a. If discharge is observed, was the conveyance man-made?
b. If discharge is observed, did it reach Surface Water? (If yes, notify DWQ)
c. If discharge is observed, what is the estimated flow in gaVmin?
d. Does discharge bypass a lagoon system? (If yes, notify DWQ)
3. Is there evidence of past discharge from any part of the operation?
4. Were there any adverse impacts to the waters of the State other than from a discharge?
5. Does any part of the waste management system (other than lagoons/holding ponds) require
4/30/97 maintenance/improvement?
❑ Yes )] No
❑ Yes XNo
❑ Yes 4No
❑ Yes �&o
❑ Yes W.No
❑ Yes ,XNO
❑ Yes No
❑ Yes o
Continued on back

Facility Number:... 53.7........
�.....
6✓Is facility not in compliance with any ap0able setback criteria in effect at the time of dle?
7. Did the facility fail to have a certified operator in responsible charge?
8. Are there lagoons or storage ponds on site which need to be properly closed?
Structures (Lagoons and/or Holding Ponds)
9. Is storage capacity (freeboard plus storm storage) less than adequate?
Freeboard (ft): Structure 1 Structure 2 Structure 3 Structure 4
3
10. Is seepage observed from any of the structures?
11: Is erosion, or any other threats to the integrity of any of the structures observed?
12. Do any of the structures need maintenance/improvement?
(If any of questions 9-12 was answered yes, and the situation poses an
immediate public health or environmental threat, notify DWQ)
13. Do any of the structures lack adequate minimum or maximum liquid level markers?
Waste Application
14. Is there physical evidence of over application?
(If in excess of WMP, or runoff entering waters of jhe State, notify DWQ)
❑ Yes �PNo
Structure 5 Structure 6
❑ Yes c] No
❑ Yes j�JINo
15.
Crop type 1GiQ` .1.. LQ2.".!...)......................................................................................
16.
Do the receiving crops differ with those designated in the Animal Waste Management Plan (AWMP)?
❑ Yes
XNo
17.
Does the facility have a lack of adequate acreage for land application?
❑ Yes
�Ao
18.
Does the receiving crop need improvement?
❑ Yes
No
19.
Is there a lack of available waste application equipment?
[I Yes
No
20.
Does facility require a follow-up visit by same agency?
❑ Yes
o
21.
For
Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
Certified Facilities Only
❑ Yes
/XNo
22.
Does the facility fail to have a copy of the Animal Waste Management Plan readily available?
❑ Yes
❑ No
23.
Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
❑ No
24.
Does record keeping need improvement?
❑ Yes
❑ No
Comments, (refer to question i): Expmlaany, YES answers and/or any recommendations or any othermm coents
—
Use drawings of facility to better explain situations uses tional pages as necessary)
4t/t7 pao iik4j (/ occr� r7f_,/�c po� �N-z-P�/0�[/
Reviewer/Inspector Name
Reviewer/Inspector Signature: ika j C
Date:
cc: Division of Water Quality, Water Quality Section, Facility Assessment Unit 4/30/97

State of North Carolina
Department of Environrrl�
and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Wayne McDevitt, Secretary
Kerr T. Stevens, Director
CERTIFIED MAIL
RECEIPT REQUESTED
Thomas Shore
Providence Farm
Rt 1, Box 55-M
Pine Hall NC 27042
Farm Number: 85 - 7
Dear Thomas Shore:
1 0
Numon. Fin
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
April6, 1999 RECEIVED
N.C. Dept. of EHNR
APR 12 1999
Winston-Salem
Regional Office
You are hereby notified that Providence Farm, in accordance with G.S. 143-215.1 OC, must apply
for coverage under an Animal Waste Operation General Permit. Upon receipt of this letter, your farm
has six 60 days to submit the attached application and all supporting documentation. In accordance
with Chapter 626 of 1995 Session Laws (Regular Session 1996), Section 19(c)(2), any owner or
operator who fails to submit an application by the date specified by the Department SHALL NOT
OPERATE the animal waste system after the specified date. Your application must be returned
within sixty (60) days of receipt of this letter. Failure to submit the application as required may also
subject your facility to a civil penalty and other enforcement actions for each day the facility is operated
following the due date of the application.
The attached application has been partially completed using information listed in your Animal
Waste Management Plan Certification Form. If any of the general or operation information listed is
incorrect please make corrections as noted on the application before returning the application package.
The signed original application, one copy of the signed application, two copies of a general location
map, and two copies of the Certified Animal Waste Management Plan must be returned to complete the
application package. The completed package should be sent to the following address:
North Carolina Division of Water Quality
Water Quality Section
Non -Discharge Permitting Unit
Post Office Box 29535
Raleigh, NC 27626-0535
If you have any questions concerning this letter, please call Dianne Thomas at [phone]
extension 364 or Ron Linville with the Winston-Salem Regional Office at (336) 7714600..
Z-1-
/
for Ken T. Stevens
cc: Permit File (w/o encl.)
Winston-Salem Regional Office (w/o encl.)
P.O. Box 29535, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post -consumer paper