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ified Operator: Longitude:
k ep operator: Latitude
cation of Farm
Cur
Design Current
Design xo
Current Ca actt Pop. Cattle' �Ca aCl PQp
`Design Wet Poultry p Y.n . ,
• t x
Capacity Pop.
Swine, Layer Dal y Cow
' Non -Layer Daily Calf
Wean to Finish
Wean to FeederEl
a`, Daily Heifer
Feeder to Finish Design, oCurrent; Dry Cow
Farrow to Wean Dry Poultry Ca Pa'& P0. ` Non-Dai
Farrow to Feeder tas Beef Stocker
Farrow to Finish Layers Beef Feeder
Gilts sBeef Brood Cow
Boars eys
Oth er Turkey Poults
Other'
y•scharues and Stream Impacts ,--,�
1. Is any discharge observed from any part of the operation? ❑Yes I1VO ❑ 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 DWR) 0 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 DWR) ❑ Yes ❑ No ❑ NA ❑ NE
2. Is there evidence of a past discharge from any part of the operation? ❑ Yes E?�4o ❑ 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?
Page 1 of 3 S/12112020

Date of Ins ection:
Facility Number: '
❑ Yes
plus storm g yes No ,
storage plus heavy rainfall)tural freeboard?
less than adequate? \o
Waste Collection &Treatment
aci structural ❑ ❑
4. Is storage cap tY
a. If yes, is waste level into the structural Structure 4 Structure 5 Structur
Structure 1 Structure 2 Structure 3 \
Identifier: - --------
Spillway":
Designed Freeboard (in):
Observed Freeboard (in):
Yes gr<o ❑NA
immediate threats to the integrity of any of the structures observed?
5. Are there any �o ❑ NA ❑
(i.e., large trees, severe erosion, seepage, etc.) ❑ yes
6. Are there structures on -site which are not properly addressed and/or managed through a
waste management or closure plan? public health or environmental threat, notify DWR
If any of questions 4-6 were answered yes, and the situation poses an immediate p Q4[]No
No ❑ NA ❑ NE
es
7. Do any of the structures need maintenance or improvement? ❑ yes o ❑ NA A
8. Do any of the structures lack adequate markers s required
et stacks)
y the permit?
(not applicable to roofed pits, dry
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 E�'<o ❑ NA
❑ 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): G Cvl/1 Ljy��/��l�lf7zr<c��I�lu f lSlo! �c"4�!A
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?
Reauired Records &_Documents
❑ NE
0 Yes
[E]No
❑ NA
❑ NE
❑ Yes
[,]No
❑ NA
❑ NE
❑ Yes
*No
❑ NA
❑ NE
❑ Yes 2- o ❑ NA o❑ NE
❑ Yes [!] No ❑ NA ❑ NE
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
La *No
❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
Q'No
❑ NA ❑ NE
the appropriate box.
❑ WUP ❑ Checklists ❑ Design ❑ Maps ❑ Lease Agreements
❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
O No
❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis
❑ Waste Transfers
❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rainfall Inspections ❑ Sludge Survey
Inspections
22. Did the facility fail to install and maintain a rain gauge?
❑ Yes
❑ 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
511212020 C

-qqqq

Facility Number: - Date of inspection: —
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes F,_�KNo
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes ® o
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge? ❑ Yes Imo' o
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes ETo
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
33. Did the Reviewer/Inspector.fail to discuss review/inspection with an on -site representative?
34. Does the facility require a follow-up visit by the same agency?
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ Yes EJIN/o ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
[-]Yes ENo ❑ NA ❑ NE
❑ Yes 0"No ❑ NA ❑ NE
❑ Yes a10
❑ Yes [INo
❑ Yes E? o
❑ NA ❑ NE
❑ NA ❑ NE
❑NA ❑NE
Comments (refer to question ft Explain any YES answers and/or any additional recommendations or any other comments- -7-
.
Use drawings of facility to better explain situations (use additional pages as necessary).
AQd r-- 'ti
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone:®
Date: — % —2?4;?z3
511212020