830015_Routine_20210802 (2)

Facility Number
G
0 Division of Water Resourcesl 1
Division of Soil and Water Conservation
0 Other Agency t t
Type of Visit: 0 Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: 0 Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit:
Farm Name:
Owner Name:
Arrival Time:
9:.a
rnw form 1
rn gJ forrn S (,11C
Mailing Address:
Physical Address:
Facility Contact:
Departure Time:
On
Owner Email:
Phone:
tIdflCounty:7(O d Region: F (,
CUrtrS BIM)1L1<
Onsite Representative: (DO rn
Certified Operator: �� brocuiv
Back-up Operator:
Location of Farm:
Title: 1 C�
Latitude:
Phone:
Integrator: cifnitfifret4
Certification Number: l 0 9 230
Certification Number:
Longitude:
Swine
Design Current
Capacity Pop.
Wean to Finish
1 1
(00(16
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Boars
Other
Wet Poult
Design Current
Capacity Pop.
Layer
Non -Layer
Dry Poultry
Design Current
Capacity Pop.
Layers
Non -Layers
Pullets
Turkeys
Turkey Poults
Other
Cattle
Design Current
Capacity Pop.
Dairy Cow
Dairy Calf
Dairy Heifer
Dry Cow
Non -Dairy
Beef Stocker
Beef Feeder
Beef Brood Cow
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 INO ❑ NA ❑ NE
❑ Yes o ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
,Z)
0 Yes o ❑ NA ❑ NE
❑ Yes Ja-No ❑ NA ❑ NE
❑ Yes 0 No ❑ NA ❑ NE
Page 1 of 3
5/12/2020 Continued

Facility Number:
Waste Collection & Treatment
Date of Inspection: 8. ! r,
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
0 Yes
O Yes
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5
N
i9
130
5. Are there any immediate threats to the integrity of any of the structures observed?
(i.e., large trees, severe erosion, seepage, etc.)
❑ Yes
No ❑ NA ❑ NE
No ❑ NA ❑ NE
Structure 6
❑ NA ❑ NE
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?
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
10. Are there any required buffers, setbacks, or compliance alternatives that need
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below.
El Yes No ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
❑ Yes nNo ❑NA ❑NE
❑ Yes No ❑ NA ❑ NE
❑ 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): € i l ) C (L O V " Gee_ (1
13. Soil Type(s): NOi : plcC. a
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? ❑ Yes t 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 EChecklists ❑ Design ❑ Maps ❑ Lease Agreements ['Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Tran ers ❑ Weather Code
El Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections El Monthly and 1" Rainfall Inspections ❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes n No El NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes ❑ No ❑ NA El NE
Page 2 of 3 5/12/2020 Continued
❑ Yes No ❑ NA ❑ NE
❑ Yes No El NA ❑ NE
❑ Yes Eallo ❑ NA ❑ NE
El Yes No ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE

Facility Number:
Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit?
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check
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:
❑ Yes`"❑,.No ❑ NA ❑ NE
❑ Yes ❑rNo ❑ NA ❑ NE
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? n Yes ❑ No ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes -❑. No ❑ NA ❑ NE
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern? ❑ Yes 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 ❑ NA ❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility?If es check the appropriate box below. Yes�10 NA NE
Y❑❑ ❑
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes ❑'hhlo ❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative'? ❑ Yes I `Y No ❑ NA ❑ NE
0.
34. Does the facility require a follow-up visit by the same agency? ❑ Yes-.❑ No ❑ NA ❑ NE
Comments (refer to question #): Explain any YES answers and/or any additional recommendations or any other comments.
Use drawings of facility to better explain situations (use additional pages as necessary).
Reviewer/Inspector Name:
uF.,
i
Reviewer/Inspector Signature:
471(
�, f dill
Phone:
Date:
Page 3 of 3 2/4/2015