780036_Certification Form_20201114

ANIMAL FACILITY ANNUAL CERTIFICATION FORM
C'eatificate of Coverage or Permit Number ' 11)-57g/0 03_
‘6 -li-
"C-• 1-1-2- 7 'ire _;)
Facility Name (as shown on Certificate of Coverage or Permit)
Operator in Charge fbr this Facility
e, unty ,17 e .11
L1iJ.
W/C
Zettification #
• ..LE-uld application of animal waste as allowed by the above permit occurred during the past calendar year.' • -
t- YE,S NO. If NO, skip Part I and. Part li and proceed to the certification. Also, if anirn'g ,, , •:
. was generated but not land applied, please attach an explanation on how the animal waste was handled. ' •
Pall I : - Falirty litiraitlalittion:
, .
I. • Total number of application Fields L! or Pulls 0 ( 1 ' -cise check the appropriate box) in the Certified Aniri),,,,--:,
, . .
Waste Manaciement Nan (CAWMP): :71 r _2 •
v,
Total Useable Acres approved in the CJ
' ) (;( ,2(_,..
2. Total number of Fields 0 or Pulls i4ease check the appropriate box) on which laud application
occurred during the year: 72.) )--0 Total Acres on which waste was applied
3. Total pounds of Plant Available Nittouen (PAN) applied during the year for all application sites: , , - 2. ,"'••-: ,.',q
.:. ..:
Total pOunds of Plant Available Nitrogen (PAN,r) allowed to bd.- land applied anquolly by the CAV-•••.-_,..t.;
the permit: ,126 _I---„,-'.
l'
5.. • Estimated amount of total manure litter and process wastewater sold or given to other persons and ,I,a?-.
....--‘,,
off site during the ycar ()
,..-- on Li or 1..?„allon& 0 (please cheek il.u. appropi-iate b.'-', -
6. Annual. average number of animals by type at this facility during the previous year:
7, La' and Laid sinallest uninber of animals by type at this facility at any one time during the previous year;
Largest 3 5 (2 0
Smallest ;
(These rittinbcrs are ibl: iriforniatio3:42 puisp3;cs oaly shee th only 1.)cirnit limit on the uuinUe ofanin
at the facility is the annual average numbers)
8. Facility's Integrator if applicable:
-Pali11:FaCilliiV Siatus:
IF THE ANSWER TO ANY STATEMENT BELOW iS "NO", PLEASE PROVIDE A WRITTEN
DESCRIPTION AS TO WHY THE FACILITY WAS NOT COMPLIANT, THE DATES OF ANY NON
COMPLIANCE, AND =LAM CORRECTIVE ACTION TAKEN OR PROPOSED TO BE TAKEN TO
BRING THIS FACILITY BACK INTO COMPLIANCE.
1, Only animal waste generated at this facility was applied to the permitted sites during
the past ::,:i1eridar year.
•
1-i
SH1IVIS 9E0S”SOTE
TO :00 90117: TiD • •

,..,•
2, Me facility was operated in such, a way.that there was no direct =ofof waste from aYes
the facility (including the houses, lagoons/storage ponds and the application sites) during
the past c..aiendar year.
hre was I:10 Cli$Oharge waste to surface water from this facility during the past E s'Zs L
calen(iar year.
There was no freeboard violation in any lagoons or storage ponds at this facility during
the past calendar
7 There was no PAN application to any fields or crops at this facility greater than the
levels specified in this facility's CAWMP during the past calendar year. • • .
„
3 . All land application equipment was calibrated at least once during the past calendw year.
.7. 'Sludge =cumulation in all lagoons did not exceed the volume for which the 171goon 1;1/Yes
was designed or reduce the lagoon's minimum treatment volume to less than, the volume
- for which the lagoon was designed.
8. A copy of the Annual Sludge Survey Form for.thi. futility is attached to this Certification., Er Yes,
9. Annual soils analysis were performed on each field receiving 'animal waste during the 10 Yes ii
past calendar year.
9, Soil pH was maintained as spocified in the permit during the past calendar Year? Ye •
f.), A.11 required monitoring and reporting was petformed in accordance with the facility's c,',1 Yes -Li
• • permit during the past calendar year.
9. All operations and maintenance requirements in the permit were complied with during ,0 Yes_
the past calendar year or, in the case of a deviation, prior authorization was received- •
from the Division of Water Quality.
3
9. Crops as specified in the CAWMP were maintained during the past calendar year on all
sites receiving anirnal waste and the crops grown were removed in accordance with
the facility's permit.
All buffer requirements as specified on the permit and the CAWMP for this facility were L]
maintained during each application of anhnal waste during the past calendar year.
"I certify under penalty of Law that this document and all attachments were prepared under ray clireetionOr
supervision in accordance with a system designed to assure that qualified personnel properly gather and
the information submitted. Based on my iniquity of the person or persons who manage the system,
those persons directly responsible for gathering the information, the information submitted is, to the best of
my knowledge and belief, true, accurate, and complete, am aware that there are significant penalties for
sign -fait -ling false i_ttformation, including,the possibility of files and imprisonment for knowing violations.- .
iq Cit-67' Cs: e_... ./
Permittee Name and Title (type or pridt)
Silmatore of-Penni-dee
Signature of Operator in Charge
(if different from Permittee)
ea
Date
HLI
HS;
'IF:OS.1117R1TE ftl: CIO 920r_ .

Appendix 1. Lagoon Sludge Survey Form : FLsevised August 2008
A. Farm Permit or DWQ Identification Number . [ `/-��
B. Lagoon Identification 7 r 11
C. Person(s) Taking Measurements 11('S', /, C2r / ,1 rq
D. Date of Measurements
E. Methods/Devices Used for Measurement of:
a. Distance froru the lagoon liquid surf toe top of the sludge layer:
b. Distance from the lagoon liquid surface to le bottom (soil) of the lagoon:
C. rJ
c. Thickness of the sludge layer if making adirect m .as ement with "core sampler":
F. Lagoon Surface Area (using dimensions at inside top of bank)' :!� 0 1 (acres)
(Draw a sketch of the lagoon on a separate sheet, list dimensions, and calculate surface area. The lagoon n:;t ;.
have been built different than designed, so measurements should be made.)
G. Estimate number of sampling points:.
a, Less than 1.33 acres: Use 8 points
. b. If more than• 1.33 acres,.2,P' j acres x 6 = , with maximum of 24.
(Using sketch and dimensions, develop a uniform grid that has the same number of intersections as the
estimated number of sampling points needed. Number the intersection points on the lagoon grid so that
data recorded at each can be easily matched.)
?1- Coacttict sludge survey and record data on'Sludge Survey Data Sheet" (Appendix 2). ,=+use, at the 1+3i'd.Fio _?".
tb& pump intake, take measurement of distance from liquid surface to tc p of sludge layer and -fern r,d it,
&n the Data Sheet (last row); the.s must be at least 2,5 ft. when irrigating.
I. At the time of the sludge survey, also measure the distance from the Maximum Liquid Level to the Present
Liquid Level (measure at the lagoon gauge pole): j
3. Determine the distance from the top of bank to the Tviaximum Liquid Level (3
(use lagoon management plan or other Iagoon records)
K. Determine the distance from the Maximum Liquid Level to the Minimum Liquid Level l•
0_G
(use lagoon management plan or other lagoon records)
L. Calculate the distance from the present liquid surface level to the Minimum Liquid Level l� _
(1teaie K 'nines /tent I, assuming the present liquid level is below the Maximum Liquid Level):
NI, Record from the Sludge Survey Data Sheet the distance from the present liquid surface level to the lagoon
bottom (average for all the measurement points): 1 (1, 0
N. Record from the Sludge Survey Data Sheet the distance from the present liquid surface level to the top of the
sludge layer (average for all the measurement points): „� r
L. Record from the Sludge Survey Data Sheet the average thickness of the sludge layer:
P. Calculate the thickness of the existing Liquid Treatment Zone (Item N emitters Item I ):,
Q. If Item 0 is greater than Item P, proceed to the Worksheet for Sludge Volume and Treatment Volume.
It Irvin 0 is equal to or less than Item P, you do not have to determine volumes.
vi
) Completed by: (Ck Ll vvs.i` L (i G )Cl c, v Date: I / if " + '2
Print Narne . Signature
'3HI 1113 •
Ost't a=1I.F, i.a•:i_ii 00 ?.;

App.:v.:Aix 2. S.14.0go. Surwy Dab) Sheet*
'7 Lagoon klentiNcation: '4 3 _6:7
corripw.€4 6:10,11Av„c. 7720—
.
Print Narne. Signature
Revised August 2
91---2,)
• , (8) ..
arid Diednce from liquid
- . Poin surface to top of sludge
(C) (G).rninus (B) .'
Distance from liquid surfaoa Thidcrse.-ss of sludge layer
to lagoon bottom (soil)
-
r4o. 1
1 F-1.. 8, in_
Ft 'tenths
Ft. & in.
Ft. (tenths) FL & in.
Ft_ (tenthsi
..
1 1 1 • `'"6
•
,
N. b . 7
) Z_
2 r•
b ‘.
-
7, .7
1(.5D -
.o,
...____ _
.
5 v
7
To.'
Illo.. I
7 • s.
,
6 . ?, c/
. 1
o ,
- 0 .
-
• --,';', S''
i N D
_ _.7,_
,
0.6)
•(i.)- 0 ,
:: , 2—
.
. • C) . .
0 ) -
7_, 3
. N
hI
. ) b • .
0 - 0 2 , Li
.,--).
11 , S'
,
7 ,
. ,-;
12 - 4
, .
_ (,)„ 6
I 1 •
, r
13 r
1-
1.4 1
mon
15
IIIIIIIIIII
16 I
min
7 1
1I
•
.1 .
_ ,9
20
- ------,
_
' 21
'22
23
MM
.._
24
•MN=
111111111111111
Nuiragsr of
po--igits wiiiti
r--: ---- X 11111.11111111111M1
AVera00
of
rcuira
NE .
i 0. . 7 , (--i
At
rfan-fip
1.1.1te
X
X
X
X
*.Ail Grid Points and corresponding sine laycr thicknesses most be shown on a sketch attached,
Sude Sarvey_Data Sheet. See Appendix 4 for couvarsion flora incites to tth ofa foot
S:Ott'EE1iE T. : i 7. /

Appendix 3. Worksiieet for sludge volume and treatment volume Revised August
•
The average thickness of the sludge layer and the thiclaiess of the existing liquid (sludge-free)rearrnr',,,
zone.(are detez-fined from informatiora'on the Lagoon Sludge ?llr'F'e}'' Form (1te13S 0 area 2; i `t;}`) t1A>.:t';
In this example, the average sludge layer thickness is 2:5 feet and the existing liquid treatment zot,e.is
.feet. If the lagoon has a. de. igned•sfudge storage volume, see.notes at end of the:worksheet. The
. 'dirltensians of the lagoon.as measured and the side slope'are needed for calculations of sludge:volume
and.of total treatment volume. If the lagoon is a standard geometric shape, the sludge volume and
treat:Meat volume in the lagoon can be estimated by using standard equations. For approximate volumes
of rectangular lagoons with constant side Slope, calculate length and width at the midpoint of tbe layer,
and multiply by layer thickness to calculate laver volitmc, as shown in the example. For irregular shapes,
convert the total surface area to a square or rectangular shape. For exact volumes for lagoons with
constant side slope, the "Prismoidal Equations" may be used.
Example Your lagoon
169, 860 .CO
10. Thickmess of existing liquid tmt. Zone (Y) 3_3 ft__
11. Thickness of total treatment zone (Z)
Z = 4- Y
(Appeadia 3 continued on next page)
I. Average Sludge Layer Thick! .ss (T) 2.5 ft.
2. Depth of lagoon from top of bank •
to bottom soil surface (D), 1 I fi.
3. Slope = horizontal/vertical side slope (S) 3
4, Length at top inside bank (L,) 457 ft. ?(A
5. Width at top inside bartk (W) 229 ft.
6. Length at midpoint of sludge layer
1r� = L — 2 S (la- (T/2)) 3913.5 ft-
7. Width at midpoint of sludge laver
Wn, = W — 2 S (D — (T/2)) 170.5 ft.
8. Volume of sludge (Vs):
TsaImWmT
9. Volume in gallons: -
Vsb =V * 7.5 gal./ft'. 1 273,950 fral. 2' 2Z , 3
SHi INS
TA cfria,--L1TO

I c2, giit 1 8445 [-I 3
St...1 I T H.7-;
1
,T>

qi::17iott811E
:013 S.C.207.1.

Appendix I. Lagoon Sh d e Survey Forun Revised AagnSt 2008
A. Farm.Permit or DWQ ldentiflcation Number
• B. Lagoon Identification —7 g: - 6
C. Person(s) Takieg Measurements i .Gil k, V ,1 c e
• D. Date of Measurements 2. --- J �r
E. Methods/Dev ces Used for Iv1easuretnent of
a. Distance from the boon liquid sur.,
the top oldie sludge layer:
'.l
b. Distance from the lagoon liquid surf=ac to the
bottom (soil) of the lagoon:
t. Thickness ofthe sludge layer if nla ag direct in,epsurentent with "core sampler':
F. Lagoon Surface Area (using dimensions at inside top of bank): 2 • (1 1 (acres)
(Draw a sketch of the lagoon on a separate sheet; list dimensions, and calculate surface area. The laguon.at.nv
have beery built different than designed, so measurements should' be ma€le,)
0. Estimate number of sampling points:
a. Less than 1.33 acres: Use 8 points
b_ If more than 1.33 acres,?,' V t acres x 6 = j Z , with maximum of 24_
(Using sketch and dimensions, develop a uniform grid that has the same number of intersections as the
estimated number of sampling points needed. Number the intersection points on the boon grid so that
data recorded at each can be easily matched.)
I1. Conduct sludge survey and record data on "Sludge Survey.Data Sheet" (Appettdix.2). &iso, at the loeaaioo of
the pump intake, take measurement of diStanee from liquid surface to top of sludge layer and record it
on tthSheet (last row); this must be at least 2S ft. when irrigating.
1. At the time of the sludge survey; also measure the dis�om the .Maximum Liquid Level to the Present
Liquid Level (measure at the lagoon gauge pole):
J. Determine the distance from the top of bank to the Maximum Liquid Level
(use lagoon management plan or other lagoon records)
K. Determine the distance from the Maximum Liquid Level to the Minimum Liquid Level /0, !
(use higoon management plan or other lagoon records)
L. Calculate the distance front the present liquid surface level to the Minimum, Liquid Level ) (")
():tear K mijius Item X, assuming the present liquid level is below the Maximum Liquid Level):
M. Record from the Sludge SSarvey Data Sheet the dists�trtee�from the present liquid surface level to the lagoon
bottom (average for all the measurement points): +"J dt J
N. Record from the Sludge Survey Data Sheet the distance frog lthe present liquid surface level to the top of the
sludge layer (average for all the measurement points): -7
C�. Record lrcrn the Sludge Survey Dam Sheer the average thickness ofthe siudgc layer: L 5
P. Calculate the thickness of the existing Liquid Treatment Zone (item N minus Item I,): , . 3
Q. Ef femur, 0 is greater than Item P, proceed to the Worksheet for Sledge Valuate and Treatment Volume,
if Item 0 is equal to or lass than a .rent. P, you do not hove to determine volneixes.
Completed by�'l' .e_ .)-1/
Print Name
Date: t -3
Signature
d
SHLIVI.S SE:O PV8EiTb Tt=1/T