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pe of Visit: _� Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance ;
ason for Visit: ®Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
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to of Visit: A t 1'Yla4tt ALL Arrival Time: c d!f/ 7 Departure Time: �/ E1V
°�? County: I�-l4J el Region:
rm Name: I— ar►til. '76 i � 1,Owner Email: � 1 S 3&et I �O- -c
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vner Name: �v�10��) +� �� Phone:
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ailing Address:
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iysica1 Address: 1
�cility contact: .Ili i k. 4- p KOAS Title: Phone:
'site Representative: '( Integrator: )r4 c T'L t`r-tC"
!rtified Operator: +( Certification Number: 7 U 6 7 1:3
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Eck-up Operator: Certification Number:
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nation of Farm: Latitude: Longitude: 3
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Discharges and Stream Impacts •
.Is any discharge observed from any part of the operation? ❑ Yes ❑moo ❑ NA ❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other: ,
a. Was the conveyance man-made? n Yes 0 No 4A ❑ NE
b. Did the discharge reach waters of th'e State?(If yes,notify DWR) ❑ Yes ❑ No ElfirA ❑ NE
c. What is the estimated volume that reached waters of the State(gallons)?
d. Does the discharge bypass the waste management system?(If yes,notify DWR) ❑ Yes ❑ No [ NA ❑ NE
2.Is there evidence of a past discharge from any part of the operation? ❑ Yes igir-No I/NA ❑ NE
3.Were there any observable adverse impacts or potential adverse impacts to the waters ❑ Yes Erg- n NA ❑ NE
of the State other than from a discharge?
Page 1 of 3 2/4/2015 Continued

Facility Number: - t Z Y Date of Inspection:. p1,m- Ze)
Waste Collection&Treatment
4.Is storage capacity(structural plus storm storage plus heavy rainfall)less than adequate? ❑ Yes 10'l�l0 ❑ NA ❑ NE
a.If yes,is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NE
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard(in):
Observed Freeboard(in): Z
5.Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes t[ o ❑ NA ❑ NE
(i.e.,large trees,severe erosion,seepage,etc.)
6.Are there structures on-site which are not properly addressed and/or managed through a ❑ Yes 0-115- ❑ 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 ❑' ❑ NA ❑ NE
8.Do any of the structures lack adequate markers as required by the permit? ❑ Yes Quo ❑ NA ❑ NE
•(not applicable to roofed pits,dry stacks,and/or wet stacks)
9.Do.es any part of the waste management system other than the waste structures,require ❑ Yes ElYd'o ❑ NA n NE
maintenance or improvement?
Waste Application
10.Are-there any required buffers,setbacks,or compliance alternatives that need ❑ Yes ©moo ❑ NA ❑ NE
maintenance or improvement?
11.Is there evidence of incorrect land application?If yes,check the appropriate box below. ❑ Yes [Nti" ❑ NA ❑NE
❑ Excessive Ponding ❑ Hydraulic Overload El Frozen Ground • ❑ Heavy Metals(Cu,Zn,etc.)
❑ PAN ❑ PAN> 10%or 10 lbs. El Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12.Crop Type(s): � C°b--k�� � r 56
13.Soil Type(s):
14.Do the receiving crops differ from those designated in the CAWMP? El Yes M-No ❑ NA ❑ NE
15.Does the receiving crop and/or land application site need improvement? ❑ Yes [ lo ❑ NA ❑ NE
16.Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes [i To ❑ NA ❑ NE
acres determination?
17.Does the facility lack adequate acreage for land application? ❑ Yes 11 No ❑ NA ❑ NE
18.Is there a lack of properly operating waste application equipment? ❑ Yes [OrNo ❑ 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 fNo ❑ NA ❑ NE
the appropriate box.
❑WUP ❑Checklists El Design El Maps ❑Lease Agreements ❑Other:
21.Does record keeping need improvement?If yes,check the appropriate box below. ❑ Yes 1<lo ❑ NA ❑ NE
El Waste Application El Weekly Freeboard El Waste Analysis ❑Soil Analysis ❑Waste Transfers El Weather Code
El Rainfall ['Stocking ❑Crop Yield ❑120 Minute Inspections ❑Monthly and 1" Rainfall Inspections ❑Sludge Survey
22.Did the facility fail to install and maintain a rain gauge? ❑ Yes v N ❑NA ❑ NE
23.If selected,did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes No ❑ NA ❑NE
Page 2 of 3 2/4/2015 Continued

Facility Number: - .1 2. 1 Date of Inspection:'iY/ /Y.ez it Z-
24.Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes [12'�(o ❑ NA ❑ NE
25.Is the facility out of compliance with permit conditions related to sludge? If yes,check ❑ Yes I21'I ° ❑ NA ❑ NE
the appropriate box(es)below.
❑Failure to complete annual sludge survey 0 Failure to develop a POA for sludge levels
❑Non-compliant sludge levels in any lagoon
List structure(s)and date of first survey indicating non-compliance:
26.Did the facility fail provide documentation of an actively certified operator in charge? ❑ Yes (p'SIo ❑ NA ❑ NE
27.Did the facility fail to secure a phosphorus loss assessments(PLAT)certification? ❑ Yes 171 ❑ NA ❑ NE
Other Issues
28.Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes [ o ❑ NA ❑ NE
and report mortality rates that were higher than normal?
29.At the time of the inspection did the facility pose an odor or air quality concern? ❑ Yes [ -N ❑ 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 J.4 e ❑ NA ❑ NE
permit?(i.e.,discharge,freeboard problems,over-application)
31.Do subsurface yle drains exist at the facility?If yes,check the appropriate box below. ❑ Yes altio ❑ NA ❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32.Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes [No ❑ NA ❑ NE
33.Did the Reviewer/Inspector fail to discuss review/inspection with an on-site representative? ❑'Yes [,No ❑ NA ❑ NE
34.Does the facility require a follow-up visit by the same,agency? ❑ Yes allicr. 0 NA ❑ NE
sti n..#. - lainaan YES;ansvrers and/o�r_any ailifiptialr"eco :-„y
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Reviewer/Inspector-Name: - ,1` U` Phone ( """t rJ 3 3C/
Reviewer/Inspector Signature: ___lll r'Date: 'l ddt Z02'
Page 3 of 3 2/4/2015