310152_Inspection Form and Farm Layout_20190211

Division of Water Resources
Facility Number - O Division of Soil and Water Conservation
p Other Agency
Type of Visit: &Compliance Inspection 0 Operation Review O Structure Evaluation p Technical Assistance
Reason for Visit: Routine O Complaint O Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit: Arrival Time: Departure Time: County: Region:
Farm Name: Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: (� 1 Title: Phone:
Onsite Representative: �If�-� 1 J t)�✓lQs Integrator:
Certified Operator: Certification Number:
Back-up Operator: Certification Number:
Location of Farm: Latitude: Longitude:
Design Current Design Current Design Current
Swine Capacity Pop. Wet Poultry Capacity Pop. Cattle Capacity Pop.
Wean to Finish Layer DairyCow
Wean to Feeder Non-Laver Dairy Calf
Feeder to Finish Dairy Heifer
Farrow to Wean Design Current Dry Cow
Farrow to Feeder Dry Poultry Capacity Pop. Non-Dairy
Farrow to Finish Layers Beef Stocker
Gilts Non-La ers Beef Feeder
Boars jPullets Beef Brood Cow
Turkeys
Other Turkey Poults
Other Other
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation? ❑ Yes A
No ❑ NA ❑ NI
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) ❑ 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 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 I of 3 21412015 Continued

Facili Number: - sl Date of Inspection: 2
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 KNo ❑ NA ❑ NE
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: �Z
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 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 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):
13. Soil Type(s):
14.Do the receiving crops differ from those designated in the CAWMP? ❑ Yes ❑ No ❑ NA (4 NE
15.Does the receiving crop and/or land application site need improvement? ❑ Yes ❑ No ❑ NA W NE
16.Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes ❑ No ❑ NA [M 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 ❑ 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 ❑ 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
22.Did the facility fail to install and maintain a rain gauge? ❑ Yes ❑ No ❑ NA [Z NE
23. If selected,did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes ❑ No ❑ NA �d NE
Page 2 of 3 21412015 Continued

Facili Number: Date of Inspection: ,2- 7 - G
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes ❑ No ❑ NA M NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes,check ❑ Yes ❑ No ❑ NA ONE
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? ❑ Yes ❑ No ❑ NA W NE
27. Did the facility fail to secure a phosphorus loss assessments(PLAT)certification? ❑ Yes ❑ No ❑ NA M 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 No ❑ NA ❑ NE
permit?(i.e.,discharge, freeboard problems,over-application) 10
31. Do subsurface tile drains exist at the facility? If yes,check the appropriate box below. (� Yes ❑ No ❑ NA ❑ NE
Application Field ElLagoon/Storage Pond ❑ Other: 77��''
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 [V1 No ❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency? ❑ Yes No ❑ NA ❑ NE
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Reviewer/Inspector Name: /' -77 \�(1 1Y1 'Vy", one: ��� 7fA;
Reviewer/Inspector Signature: Date:
Page 3 of 3 /� .��
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21412015

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