090049_INSPECTIONS_20171231

Type of visit: Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: tine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: /3—/ Arrival Time: CO I Departure Time: County: Region:
Farm Name: �h 6uJ f�;r y �,fjy,�� r- rr",L_ Owner Email:
Owner Name: -.-d —r G. Phone:
Mailing Address:
Physical Address:
Facility Contact: �S't7 �LL�A,�{z-7 Title: Phone:
Onsite Representative: S'�ti-� Integrator: d'
Certified Operator: ,S'.+�--�� Certification Number:
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
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 No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
[:]Yes ❑ No ❑ NA ❑ NE
❑ Yes
Design
Current
[:]NE
Design
Curren t
b .. Iia: y, P 1 . • _.: R ..,
Design Current
❑ NE
❑ Yes
0 No
❑ NA
❑ NE
tn�e
Capacity
Pop.
Wet Poultry Capacity
Pop.
Cattle Capacity Pop.
�i
Wean to Finish
„„
La er
Dairy Cow
Wean to Feeder
�i
'
iNon-Layer
Dairy Calf
eederto Finish
D'O
k� ��,'
Dai Heifer
arrow to Wean
?F
_! `, 4Bw Desrgn
C nt
D Cow
Farrow to Feeder
D , Poult.. t: Ca aci
Ah
Po
Non -Dairy
Farrow to Finish
I
lLavers
Beef Stocker
Non -Layers
Beef Feeder
Gilts
Boars
Pullets
Beef Brood Cow
Turkeys
u�
ether,
Turke Poults
kl
,
Other
Other
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 No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
[:]Yes ❑ No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
[:]NE
❑ Yes
aN
❑ NA
❑ NE
❑ Yes
0 No
❑ NA
❑ NE
Page I of 3 21412015 Continued

Facility Number: - jDate of Inspection:
Waste Collection & Treatment
( 4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes
a. If yes, is waste level into the structural freeboard? ❑ Yes
to ❑ NA ❑ NE
❑No 0 N ❑NE
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: Uj —w
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): 6;2 �
5_ Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes [3 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 E] 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 ❑'IV�o
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes F No
❑ NA
❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
9. Does any part of the waste management system other than the waste structures
require ❑ Yes E]No
❑ NA
❑ NE
maintenance or improvement?
❑ Yes
[:EN
❑ NA ❑ NE
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes No
❑ NA
❑ NE
maintenance or improvement?
18. is there a lack of properly operating waste application equipment?
❑ Yes
[j<o
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
[] NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
�o
❑ NA
❑ NE
acres determination?
21. Does record keeping need improvement? if yes, check the appropriate box below.
❑ Yes
[:EN
❑ NA ❑ NE
17. Does the facility lack adequate acreage for land application?
❑ YesNo
❑ Weather Code
❑ NA
❑ NE
18. is there a lack of properly operating waste application equipment?
❑ Yes
[j<o
❑ NA
❑ NE
Reauired Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
[ENo
❑ NA ❑ NE
20_ Does the facility fail to have all components ofthe CAWMP readily available? If yes, check
❑ Yes
[D -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
[:EN
❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis
❑ Waste Transfers
❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and I" Rainfall Inspections
❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge?
❑ Yes
❑ No
❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes to ❑ NA ❑ NE
Page 2 of 3 2/4/2015 Continued

Facility Number: D 2 - Date of Inspection:
ti 24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes No ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes D No ❑ NA ❑ NE
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 ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes 0<o ❑ NA ❑ NE
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?
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
❑ Yes Er<o ❑ NA ❑ NE
❑ Yes 12r<o ❑ NA ❑ NE
❑ Yes [?]o ❑ NA ❑ NE
[:]Yes [" No ❑ NA ❑ NE
❑ Yes
[2/No
❑ NA
❑ NE
❑ Yes
Io
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
Phone:
Date: /Z)
2/4/2015

f� 701N=
ctl�
type of visit ompliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
[season for Visit; Q Romp�utine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: 3t1 -f Arrival Time: Departure Time: County:
Farm Name: S�lal�ic[1 ��i°hh Owner Email:
Owner Name: (�(J �r rp t�Tir G. Phone:
Mailing Address:
Physical Address:
A�J11 Region:
Facility Contact: Title: r Phone:
Onsite Representative: Integrator:
Certified Operator: ��� Certification Number:
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure p 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 LQ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
[:]Yes ❑ No DNA ❑ NE
❑ Yes ❑ No
❑ Yes K No
❑ Yes 69 -No
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Page I of 3 2/4/2015 Continued
Design
Currents
Design Currents Design Current
Swine
C•a acit
Po Wet P oul �Y
Ca acr Po Capacity Pop.
p tY PCattle
Wean to Finish
La er
Dairy Cow
Wean to Feeder
/Taoo
Non -La er
Dai Calf
feeder to Finish'--
_' '"
Dairy Heifer
Farrow to Wean
Design Cuter ent
Dry Cow
D . PP,oultr,
_ _
Ca acct P,�,,;1'
Farrow to Feeder
Non -Dai
Farrow to Finish
Layers
=-
Beef Stocker
Beef Feeder
Gilts
Non -Layers
Boars
Pullets
Beef Brood Cow
�.
Turkeys
Other"
g
�,-�
Turkey Poults
—a
Other..
Olt-
,..Other`.
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure p 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 LQ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
[:]Yes ❑ No DNA ❑ NE
❑ Yes ❑ No
❑ Yes K No
❑ Yes 69 -No
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Page I of 3 2/4/2015 Continued

Facili Number: - Date of Inspection: — v
—_:Pb
No
❑ NA
❑ NE
Waste Collection & Treatment
❑ Yes
® No
❑ NA
❑ NE
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
allo
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
[] No
❑ NA
❑ NE
Structure 1 Sturc 2 Structure 3 Structure 4
�r
Structure 5
Structure 6
❑ NA
Identifier:
the appropriate box.
Spillway?:
Designed Freeboard (in): tel_
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
E 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
P 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
T Do any of the structures need maintenance or improvement?
❑ Yes
)a No
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
r_%'1 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
[allo
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
FNo
❑ NA
❑ NE
maintenance or improvement?
11, Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes EZNo ❑ 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): /"�GVIx
13. Soil Type(s): �' �•.�
14. Do the receiving crops differ from those designated in the CAWMP? [:]Yes 0 No ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? [:]Yes 0 No ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable [--]Yes 0 No ❑ NA ❑ 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
21 No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
EKNo
❑ NA
❑ NE
the appropriate box.
❑WUP ❑Checklists ❑ Design [] Maps ❑ Lease Agreements F] Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes J�j No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and I" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes ® No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? [] Yes allo
0 NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 21412015 Continued

FaciliNumber: - I Date of Inspection:/ 3c7—/
j 24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes .0 No ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes [Z No ❑ NA ❑ NE
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 fust survey indicating non -compliance -
26. Did the facility fail provide documentation of an actively certified operator in charge?
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
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?
[] Yes jo No ❑ NA ❑ NE
❑ Yes � No ❑ NA ❑ NE
❑ Yes J�'j No ❑ NA ❑ NE
❑ Yes K No ❑ NA ❑ NE
❑ Yes [2�No ❑ NA ❑ NE
❑ Yes _0 No ❑ NA ❑ NE
❑ Yes allo
❑ Yes MNo
❑ Yes E No
❑ NA ❑ NE
❑ NA ❑ NE
❑ 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:
Reviewer/Inspector Signatui
Page 3 of 3
Phone:7l> ,ra'olSJ
Date:
2/4/2015

i
Type of Visit: .Q'Compliance Inspection O Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit: outine O Complaint O Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit: Arrival Time: /O; raj Departure Time: County: n� Region: J�%S
r—
Farm Name: ��/ OwnerEmail:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: `j�jcYi J V vA Title: e!7lf Phone:
�7
Onsite Representative: Integrator: S �_ �Y
Certified Operator: Certification Number: /1. �l
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
DischarjZes 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?
[:D Yes � No E] NA E] NE
❑ Yes [:]No
❑ Yes [:]No
❑ Yes [:]No
❑ Yes 2_No
❑ Yes f?!jNo
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Page 1 of 3 21412015 Continued
Design
Current
Design
Current=
Design C•urcent
Swine
Capacity
Pop. WetiPoultry
Capacity
Pop.
Cattle Capacity Pop.
Wean to Finish
Layer
Dairy Cow
Wean to Feeder
p -0
14000 Non -La er
I
Dairy Calf
Feeder to Finish
-V �
Dairy Heifer
Farrow to Wean
Design
Current
Dry Cow
Farrow to Feeder
p
DryIPouit�
Ca aci_
P,o
Non -Dai
Farrow to Finish
Layers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turkeys
` :*
OtherW.
Turkey Poults
JIF–Ft–her
Other
DischarjZes 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?
[:D Yes � No E] NA E] NE
❑ Yes [:]No
❑ Yes [:]No
❑ Yes [:]No
❑ Yes 2_No
❑ Yes f?!jNo
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Page 1 of 3 21412015 Continued

- l k -- ;�-19/�-
Facili Number: - Date of Inspection:
j Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes
a. If yes, is waste level into the structural freeboard? ❑ Yes
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5
Identifier:
Spillway?: _
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
(i.e., large trees, severe erosion, seepage, etc.)
® No ❑ NA ❑ NE
❑No ❑NA ❑NE
Structure 6
❑ Yes � No ❑ NA ❑ NE
6. Are there structures on-site which are not properly addressed and/or managed through a
[:]Yes
allo
❑ NA
❑ NE
waste management or closure plan?
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑
Failure to Incorporate Manure/Sludge into
Bare Soil
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
E� 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)
❑ Yes E"No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
9. Does any part of the waste management system other than the waste structures require
❑ Yes
No
❑ NA
❑ NE
maintenance or improvement?
❑ NE
acres determination?
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 allo
❑ 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 Wind/ow ❑ Evidence of Wind D/riRE]
Application Outside of Approved Area
1
12. Crop Type(s): t
13. Soil Type(s): �(V'd^ -�-•�-
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes E"No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes ® No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes ® No
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
❑ Yes E4 No ❑ NA ❑ NE
❑ Yes E�g_No ❑ NA ❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes E_No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes �o ❑ 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
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and l" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes E2 No
23. If selected, did th6 facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes 0—No
Page 2 of 3
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
DNA ❑NE
21412015 Continued
A

Facility Number: `j' - L2 jDate of Inspection:
f 24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes ® No ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes fZ No ❑ NA ❑ NE
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 fust survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge?
❑ Yes
[a No ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
❑ Yes
® No ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
ID 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)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Yes
® No ❑ 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
R No ❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
�o ❑ 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: 57; Z'
Reviewer/Inspector Signature:
Page 3 of 3
Phone: I __3 `U/_3
Date:
2/412015

Ii ype or visit: y_--j-uompuance rnspecuon V vperanon rceview tJ a�rrucrure r.varunnon V i ecnmcal Assistance
Reason for Visit: outine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: LrJ Arrival Time: , �D O Departure Time: County:
Farm Name: �j�jQ�©�(J..� �} �r-b�iY/" �ar'r�� Owner Email:
Owner Name: /,(fr_ f9bry- Phone:
Mailing Address:
Physical Address:
Region:
Facility Contact: �� y amu_ Title: Phone:
Onsite Representative: 3�'�-r� Integrator:
Certified Operator: Certification Number:
Back-up Operator:
Certification Number:
Location of Farm: Latitude: Longitude:
Milli
F19ign Current
CF;kNo
Design Current
Design Current
Swine
Capacity Pop.
Wet�Poultry
Capacity Pop.
Cattle Capacity Pop.
a. Was the conveyance man-made?
Wean to Finish
❑ No
La er
❑ NE
Dairy Cow
❑ Yes
Wean to Feeder
pv
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
Dairy Calf
eeder to Finish
/
d. Does the discharge bypass the waste management system? (If yes, notify DWR)
Dairy Heifer
Farrow to Wean
❑ NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
Dry Cow
Farrow to Feeder
0
❑ NE
a N Po
Non -Dairy
Farrow to Finish
❑ NA
Layers
of the State other than from a discharge?
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turkeys
Other_01 :.,
Turkey Poults
Other
10ther
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
[:]Yes
CF;kNo
❑ 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)
❑ 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
allo
❑ NA
❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters
❑ Yes
in -No
❑ NA
❑ NE
of the State other than from a discharge?
Page 1 of 3 2/412014 Continued

Facili Number: st - Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
0 No
❑ NA
❑ NE
a. if yes, is waste level into the structural freeboard?
❑ Yes
❑ No
❑ NA
❑ NE
Structure 1 Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier: rH
Spillway?:
Designed Freeboard (in): �� '91_
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
E4 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 DWQ
7. Do any of the structures need maintenance or improvement?
❑ Yes
M No
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
g 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
[a No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
[RNo
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below.
[:]Yes
FX.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 ❑ nce of Wind Drift ❑ Application Outside of Approved Area
Evi
12. Crop Type(s): /y t "'L
z
13. Soil Type(s): z=
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes [ANo ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? [:]Yes RjNo ❑ NA ONE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes KNo ❑ NA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
❑ Yes [�No ❑ NA ❑ NE
❑ Yes 24,No ❑ NA ❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes allo ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? if yes, check ❑ Yes �. o ❑ 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 [aNo
❑ Waste Application p Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1 " Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes [ONo
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 2/4/2011 Continued

3 a aois
Facili Number: - Date of Inspection: —
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes E�No ❑ NA ❑ NE
+ 25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes D�[_No ❑ NA ❑ NE
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 nNo ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes [& No ❑ NA ❑ NE
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?
❑ Yes MNo E] NA E] NE
❑ Yes allo ❑ NA ❑ NE
❑ Yes ®..No ❑ NA ❑ NE
❑ Yes E4 No ❑ NA ❑ NE
❑ Yes No
❑ Yes ® No
❑ Yes No
❑NA ❑NE
❑ NA ❑ NE
❑ NA ❑ NE
Comments (refer to question ft 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
Phone: G'15�90
Reviewer/Inspector Signature: Date: (�
Page 3 of 3 2/4/2011

M1
,
' ivision of Water Quality
Facility Number ®- y Division of Soil and Fater Conservation
OO Other Agency
Type of Visit:om nce Inspection Operation Review Q Structure Evaluation Q Technical Assistance
Beason for Visit: Routine 0 Complaint O Follow-up O Referral O Emergency O Other 0 Denied Access
Date of Visit: Arrival Time: Departure Time: ; D County: l�
Farm Name 6-Iryt,o)' r��� Owner Email:
Owner Name: Vj-41111r ' 64 / �Phone:
Mailing Address:
Physical Address:
Region: 14_� D
Facility Contact: 75 & jj2LU uTitle: /i�arr��✓ Phone:
Onsite Representative: Integrator: /1L,�•�-�
Certified Operator: Certification Number:
Back-up Operator:
Location of Farm:
Latitude:
Certification Number:
Longitude:
Discharses 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 DWQ)
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 DWQ)
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 ® No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
[:]Yes ❑ No
❑ Yes ® No
[:]Yes E�_No
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Page I of 3 214/2011 Continued
Design
Current
Design
Current
Design Current
Swine
Ca aci
...,�P tY
Po P•
r
et Poult : _
- ,...� J'
Ca aci_
� P _ tY
Po P•
Cattle Ca aci Po
P tY P•
�
Wean to Finish
Layer
Dairy Cow
71 Wean to Feeder
pp
( 8 civ
Non -Layer
Dairy Calf
Feeder to Finish
77nC2p
;7.ODa
F''
" `
Dairy Heifer
Farrow to Weanp
pto c`i
Design
Current
Dry Cow
Farrow to Feeder
-D' ,Poul
Ca aci_
Pio
Non -Da'
Farrow to Finish
Layers
Beef Stocker
Gilts Non -Layers
Beef Feeder
Boars Pullets
Beef Brood Cow
I pi Turkeys
Othe_r
_
Turkey Poults
Other
I
Other
Discharses 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 DWQ)
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 DWQ)
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 ® No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
[:]Yes ❑ No
❑ Yes ® No
[:]Yes E�_No
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Page I of 3 214/2011 Continued

Facility Number: -41 T7 jDateof Inspection: ~ 7—,;Z0
Waste Collection & Treatment
11 4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes allo ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
��+Stru��JJcturee Structure 1 Structure 2 Struure 3 Structure 4 Structure 5 Structure 6
�/uIdentifier'rC"--" �- W41 -.r
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes (a 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?
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into
Bare Soil
If any of questions 4-6 were answered yes, and the situation poses an immediate public health
or environmental threat,
notify DWQ
7. Do any of the structures need maintenance or improvement?
❑ Yes
0 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)
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes ®,No
❑ NA
9. Does any part of the waste management system other than the waste structures require
❑ Yes
0 No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
El 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): ee" -N- 6G4WIa71 /Syyt�ry--1 2�I
e.
13. Soil Type(s): Cp /-8ri�
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes allo
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes ®,No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes B No
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
[:]Yes ® No ❑ NA ❑ NE
❑ Yes allo ❑ NA ❑ NE
Reuuired Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes O No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check [:]Yes [3,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 B No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall [:]Stocking ❑ Crop Yield ❑ 120 Minute inspections ❑ Monthly and I" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? [—]Yes ® No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes �allo
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑NA ❑NE
❑NA ❑NE
Page 2 of 3 2/4/2011 Continued

Facility Number: Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes ® No
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes [ RNo
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 allo
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes ® No
❑NA ❑NE
0 N 0 N
❑ NA ❑ NE
❑ NA 0 NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes 0 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 MNo
❑ 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)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Yes g No
0 NA ❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes [KNo
❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on-site representative?
❑ Yes [5 No
❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes [3 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:
Reviewer/Inspector Signature:
Page 3 of 3
Phone:
Date:
2/4/2011

Type of Visit: Q-1rompliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: (91foutine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: LL�J Arrival Time: Departure Time: ; pJ County: Region: Fg O
Farm Name:�p,y �'��� I.cicb�r� �arw•- Owner Email:
Owner Name: uj�jZ�,,,� Fi�rr�s �,?�. Phone:
Mailing Address:
Physical Address:
Facility Contact: sy;'�xp ��,�� Title: Phone:
Onsite Representative: �uu_ Integrator:
Certified Operator:
Back-up Operator:
Certification Number:
Certification Number:
Location of Farm: Latitude: Longitude:
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 DWQ)
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 DWQ)
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 No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
Design Current
^
D,`e`sign
Current
Design Current
Swine
Capacity- -Pop.
Wet Poultry
Capacity
Pop.
Cattle Capacity Fop.
Wean to Finish
Layer
Da' Cow
Wean to Feeder
Feeder to Finish
pp - a —
c p
Non -La er
" `
Da' Calf
D ' Heifer
Farrow to Wean
Farrow to Feeder
,'
D , Poul- -,
Design
Ca aci_
Current
Po
D Cow
Non -Dairy
Farrow to Finish
%
Layers
Beef Stocker
Gilts
Non -La -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turkeys
Other
Other
Turkey Poults
Other
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 DWQ)
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 DWQ)
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 No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
[:]Yes
2kNo
❑ NA
❑ NE
❑ Yes
RNo
❑ NA
❑ NE
Paige 1 of 3 2/412011 Continued

(Facility Number: 611- Date or inspection:
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? C] Yes ❑ No ❑ NA ❑ NE
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: /tet
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): 3 D
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 [Z 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 DWQ
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 0 No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes allo
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes CR�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): L�r�•• /Gc��� :��y�r,s
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes 0 No ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes [3 -No ❑ NA ❑ NE
.16. Did the facility fail to secure and/or operate per the irrigation design or wettable [:]Yes B No ❑ NA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
❑ Yes No ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes E[ No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes E. 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 S No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1 " Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? [:]Yes ®.No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes M -No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 21412011 Continued

Facili Number: -EJ Date of Ins ection: — /j
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes ® No
■ 25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes ® No
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 ® No
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes [@ No
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.
El 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 [a No ❑ NA ❑ NE
❑ Yes Z No ❑ NA ❑ NE
[] Yes ® No ❑ NA ❑ NE
❑ Yes 0 No ❑ NA ❑ NE
[–]Yes [4 No
❑ Yes ® No
❑ Yes ® No
❑ NA ❑ NE
❑ NA ❑ NE
❑ 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:
Reviewer/Inspector Signature:
Page 3 of 3
Phone:
Date:
2/4/2011

Type of Visit: QKompliance Inspection Q Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: outine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: 37 Arrival Time: .'O(7 Departure Time: ,` County:
Farm Name: �j,��%,p�,i/ 1��� ll/c���i r/yt Owner Email:
Owner Name: i�/s��-C �Qls'G Phone:
Mailing Address:
Physical Address:
Region: LW --
Facility Contact: 5 _�� Title: d2jgAA�A<�' - Phone:
Onsite Representative: Integrator:
Certified Operator: ��� Certification Number:
Back-up Operator:
Location of Farm:
Latitude:
Certification Number:
Longitude:
Swine
Wean to Finish
Design ,Current
Capacity l'op.
_
Wetrl?oultry ._
La er
Design
Capacity
Current
Pop.
Design Current
Cattle C►apacity Pop.
Dairy Cow
Wean to Feeder
/ Do CJ
Non -La er
Dairy Calf
Feeder to Finish
`.
Dairy Heifer
Farrow to Wean
Design
Current
Dry Cow
�( Farrow to Feeder
pip
D > Poul_ g
Ca a_ci
Plo
Non -Dairy
Farrow to Finish
Layers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turkeys
Turke Poults
r7Other
Other
Other
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 DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
❑ Yes [Z No ❑ NA ❑ NE
❑ Yes
[:]No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
d. Does the discharge bypass the waste management system? (If yes, notify DWQ) ❑ 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 21412011 Continued

Facility Number: - Date of Inspection: 3' /
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes 0 No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in): 19 LZ
Observed Freeboard (in): 38" _M�
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
E] NA
E] 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 DWQ
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 Evidenceof Wind Drift/ [D Application Outside of Approved Area
/❑
12. Crop Type(s):�L/%tadtT / S6�d� s / �O/'�t / /A -11_0t00&
13. Soil Type(s)=
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes �No E] NA E] NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes gLNo ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes FXLNo ❑ NA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
❑ Yes No ❑ NA ❑ NE
❑ Yes [allo ❑ 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 El Checklists E] Design [❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. []Yes PS No
❑ Waste Application ❑ Weekly Freeboard p Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rainfall inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes ® No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 2/4/2011 Continued

Facili Number: - Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes [a No ❑ NA ❑ NE
25. Is the facility out of compliance with permit. conditions related to sludge? If yes, check ❑ Yes E&No ❑ NA ❑ NE
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 [&No ❑ NA [] NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes O 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?
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?
❑ Yes 0 No ❑ NA ❑ NE
[:]Yes [No [:]NA 0 NE
❑ Yes ®. No ❑ NA ❑ NE
[—]Yes Q No
❑ Yes 0 No
[::]Yes PSkNo
❑ NA ❑ NE
❑NA ONE
❑ 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 #ages as necessarv).
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: 2LP-
Date: : �/—�=au
2/4/2011

Type of Visit (Doeo-mpliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit outine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: Arrival Time:: O C7 Departure Time: / County: Region:
Farm Name: J64ean d- on- Owner Email:
Owner Name: ZVe.94 n/ %a�tn` Y—s �f7G. Phone:
Mailing Address:
Physical Address:
Facility Contact: ��il.Lvt%!�-a?a &rt7—Title: 2! !rAL- /%%T Phone No:
Onsite Representative: Integrator: %l7Uo
/01
Certified Operator: -5a-1 - Operator Certification Number:
Back-up Operator:
Back-up Certification Number:
Location of Farm: Latitude: 0 0 =1 =11
Longitude: =0=1 =
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Design Current
Design C•ur.rent
Design Current
Swerve
Capacity Popula#ion
LW,%e;t;.'.o. y�ltry, Capacity Population.
Cattle Capacity Popula#ion
Wean to Finish
Qp - r
❑ La er
❑Dai Cow
❑ No
❑ Wean to Feeder
❑ NE
❑Non -La er
❑ Da' Calf
❑ No
Feeder to Finish
% fl
c. What is the estimated volume that reached waters of the State (gallons)?
❑ Dai Heifer
Farrow to Wean
D O
Dry�Roii try :`
❑ D Cow
❑ Farrow to Feeder
❑ No
❑ NA
El Non -Dairy
❑ Farrow to Finish
❑ Yes
❑ Layers
❑ Beef Stocker
❑ Gilts
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑Non -Layers
❑ Beef Feeder
ElBoars
❑ NE
❑Pullets
10 Beef Brood Co
--
❑ Turkeys
Page 1 of 3
O#her
Continued
❑Turkey Poults
❑ Other
❑ Other I
umber of Structures:
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
9No
❑ 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 DWQ)
❑ Yes
❑ No
❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
❑ Yes
❑ No
❑ NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
JR No
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
Q No
❑ NA
❑ NE
other than from a discharge?
Page 1 of 3
12/28104
Continued

Facility Number: — Date of Inspection
❑ Yes
Liq No
❑ NA
❑ NE
Waste Collection & Treatment
❑ Yes
[,No
❑ NA
❑ NE
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
[9 No
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No
❑ NA
EINE
Structure I Structure 2 Structure 3 Structure 4
Structure
5
Structure 6
Identifie . r+n n bu"U -r -
Spil lway?:
Designed Freeboard (in): f 9 _ /9
Observed Freeboard (in): 3 % �69Z9
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
t,No
❑ NA
❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on-site which are not properly addressed and/or managed
❑ Yes
in No
❑ NA
❑ NE
through a 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 DWQ
7. Do any of the structures need maintenance or improvement?
❑ Yes
5INo
❑ NA
❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes C9 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/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes ;g 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 Area
12. Crop type(s)
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
Liq No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
[,No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?❑ Yes
9No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
5,No
❑ NA
❑ NE
18. 1s there a lack of properly operating waste application equipment?
❑ Yes
[&No
❑ NA
❑ NE
@omments,(e er-to question #4-RExp"I*ffi any YES answers ant% any recommendations or any other comm_ entc.
Use draw nygs oVfaciltty to betterezpyy situahons(use addttional1pages as necessary)s�
2 i
Reviewer/Inspector Name��ePhone:
Reviewer/Inspector Signature: Date:
Page 2 of 3 12/28/04 Continued

)Facility Number: — Date of Inspection! ri i
❑ Yes
14 No
❑ NA
' Required Records & Documents
25. Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
9 No
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes
® No
❑ NA
EINE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes
UZ No
❑ NA
❑ NE
the appropirate box. ❑ WUp ❑ Checklists ❑ Design g El Maps El Other
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
2L . Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes
54 No
[INA
❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rain Inspections ❑
Weather
Code
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes
®,No
❑ NA
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes ® No ❑ NA ❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
14 No
❑ NA
❑ NE
25. Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
9 No
❑ NA
❑ NE
26. Did the facility fail to have an actively certified operator in charge?
❑ Yes
EQ No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
® No
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
[,No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
NZNo
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30.
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
31.
Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
RNo
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on-site representative?
❑ Yes
® No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
9No
❑ NA
❑ NE
Additional Coritmeats and/or,,Draw2ngsmom
Page 3 of 3 12/28/04

9-//-249/0
ral
Type of Visit inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit (Del outine 0 complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: Arrival Time: �.'QD Departure Time: �. o0 County:
r
Farm Name:' _ UJ Cle-Aln/ Gr �Q k- Owner Email:
Owner Name: GtJr_A40� e r /� Ys.�S �nrL • Phone: _
Mailing Address:
Physical Address:
Facility Contact•�'�' 2SD (14­�94e. v Title:
Onsite Representative:
Certified Operator:N"
Back-up Operator:
Phone No:
Integrator:
Region: /C" -
Operator Certification Number: 1297 9
Back-up Certification Number:
Location of Farm: Latitude: = o =' ❑ Longitude: = ° ='
=
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Design Current
Design Current
Design C•nrrent
e
Capacity Population
Wet Poultry Capacity Population
C►attle Capacity PopWation
ean to Finish
❑ Layer
❑ Yes
❑ Da Cow
to Feeder
r[P
000
❑ Non -Layer
❑ Yes
❑ Dai Calf
Fean
eeder to Finish
200
c. What is the estimated volume that reached waters of the State (gallons)?
❑ Dai Heifer
arrow to Wean
❑ D Cow
arrow to Feeder
❑ No
❑ NA
❑ Non-Daiarrow
to Finish
❑ Yes
❑ Layers
❑ Beef Stocker
❑ Gilts
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Non -Layers
El Beef Feeder
El Boars
❑ NE
El Pullets
❑ Beef Brood Cowj
❑ Turkeys
Other
❑ Other
Continued
❑ Turkey Poults
Number of Structures:
❑ Other
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
❑ No
❑ 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 DWQ)
❑ Yes
❑ No
❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
❑ 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 adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
❑ No
❑ NA
❑ NE
other than from a discharge?
12/28/04
Continued

Facility Number: o Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes ❑ No ❑ NA EINE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: G�``6'1t'-"-
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
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on-site which are not properly addressed and/or managed ❑ Yes ❑ No ❑ NA ❑ NE
through a 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 DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes ❑ No ❑ NA ❑ NE
8. Do any of the stuctures 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/improvement?
11. Is there evidence of incorrect 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 Area
12. Crop type(s) 4 s<epA eCje , 11746-.1 farr.,ej Sa.rab'r aaI v;Al t! 0, S
13. Soil type(s) 4 e fi
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
❑ No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
❑ No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
❑ Yes
❑ No
❑ NA
❑ NE
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
Comments (refer to question #}; -Explain any YES answers and/or any'ecommendat,o`ns or�any other comments.
Use drawtn sof
facility to better ex lain situations.: use additional a e- a4,Q­--',,' a `
Reviewer/inspector Name Ren(` *l Phone:
Reviewer/Inspector Signature: Date: 27- 20IC7
12/28/04 Continued

Facility Number: Date of Inspection- Z7—
Required Records & Documents
19. Did the facility fail to have 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 El Checklists El Design [I Maps [I 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 ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield [:1120 Minute Inspections [:]Monthly and 1" Rain Inspections ❑ Weather Code
22. Did the facility fail to install and maintain a rain gauge?
❑ Yes
❑ No
❑ NA
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
❑ No
❑ NA
❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
❑ No
❑ NA
❑ NE
25. Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
❑ No
❑ NA
❑ NE
26. Did the facility fail to have an actively certified operator in charge?
❑ Yes
❑ No
❑ NA
❑ NE
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
❑ No
❑ NA
❑ NE
Other Issues
28. Were any additional problems noted which cause non-compliance of the pen -nit or CAWMP?
❑ Yes
❑ No
❑ NA
❑ NE
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
❑ No
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30. 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
31. Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
❑ No
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/Inspector fail to discuss review/inspection with an on-site representative?
❑ Yes
❑ No
❑ NA
❑ NE
33. Does facility require a follow-up visit by same agency?
❑ Yes
❑ No
❑ NA
❑ NE
A�ddi#t nall*o tsandlorDa ngs:
•
12128/04

ivision of Water Quality
=acifityumber d e) 4q O Division of Soil and Water Conservation
O Other Agency
Type of Visit ompliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit outine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: 5'"405"0 Arrival Time: I V3 Departure Time: 2 • V w. County: 614n ¢ L Region:
Farm Name: GbGz►- �aYl�•!S Tr/Cr Owner Email:
Owner Name: -�`O dG "' G ��''� �ay^" Phone:
Mailing Address:
Physical Address: �A
Facility Contact: Sart-1 c15 o JuSg t( C -A Title: �4 ��1 40lVa4G)f Phone No:
Onsite Representative: Integrator:
Certified Operator: Operator Certification Number:
Back-up Operator:
Back-up Certification Number:
i10
Location of Farm: Latitude: [� o [� ; a 64 Longitude: 0 ° [� , =
SA
Swine
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ La er
/000 0 ❑
Non-Layet
❑ Wean to Finish
Wean to Feeder
eederto Finish
2000 2c:
/o
arrow to Wean
7400 1 12_0()
❑ Farrow to Feeder
❑ Farrow to Finish
ElCiIts
[:1Boars
Other
❑ Other
Dry Poultry
❑ La ers
❑
Non -Layers
[Ell Pullets
ElTurkeys
El Turkey Poults
ElOther
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ElStructure ElApplication Field ElOther
a. Was the conveyance man-made?
... r;;.
Design Curr
Cattle Capacity P. pult
❑ Dairy Cow
[I Dairy Calf
El Dairy Heifer
El Dry Cow
ElNon-Dairy
ElBeef Stocker
ElBeef Feeder
ElBeef Brood Cowi
NurSber of Structures:
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
❑ Yes No ❑ NA ❑ NE
❑ Yes ❑ No 0 NA ❑ NE
❑ Yes ❑ No O<A ❑ NE
❑ Yes ❑ No C U NA ❑ NE
❑ Yes YJ No ❑ NA ❑ NE
❑ Yes No ❑ NA EINE
12/28/04 Continued

L
Facility Number: Oc? — 41A y Date of Inspection
❑ Yes
No
❑ NA
Waste Collection & Treatment
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
D No
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes E7 No
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes ❑ No
[3*NA
❑ NE
Structure 1 Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
identifier: S,, 6 • ft—L k"I fy # 2—
❑ Yes
No
❑ NA
Spillway?: Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): 32 Z 9 j
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes [3 No
❑ NA
❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on-site which are not properly addressed and/or managed
El�� /
Yes +� No
❑ NA
❑ NE
through a 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 DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes ECJ No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes d 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
maintenance/improvement?
❑ Yes IJ No ❑ NA ❑ NE
11. is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes Ej 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 Area
12. Crop type(s) .✓is��l dci �f�a y �K j� . Shyi&r-?1J 611e115e'd � f r�<J/ GJ �• �. I
13. Soil type(s) 0—i—, i_e A
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
D No
[INA
[1 NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?❑ Yes
LJ No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
ETNo
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
No
❑ NA
❑ NE
Comments (refer to question #): Explain any YES answers and/or any recommendations or any other comments.
Use drawings of facility to better explain situations. (use additional pages as necessary):
Reviewer/Inspector Name Phone: [phone]V
Reviewer/Inspector Signature: Date: S 05-- ZUVQ
11/18104 Continued

Facility Number: a9 — Date of Inspection S -0S -d 9
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available?
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
the appropirate box.
❑ WUP El Checklists [I Design El Maps E] 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 ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and I" Rain Inspections E]WeatherCode
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes L'1 No ,,❑,, NA [__1 NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? El Yes ElR
No NA ❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes EO ElNA [INE
25. Did the facility fail to conduct a sludge survey as required by the permit? ElD Yes , o El NA E] NE
26. Did the facility fail to have an actively certified operator in charge? ❑ Yes DN ElNA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification? ElYes No ❑ NA ❑ NE
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
and report the mortality rates that were higher than normal?
30. 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
31. Did the facility fail to notify the regional office of emergency situations as required by
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/Inspector fail to discuss review/inspection with an on-site representative?
33. Does facility require a follow-up visit by same agency?
❑ Yes Ll No ❑ NA ❑ NE
❑ Yes [3 o ❑ NA ❑ NE
Comments and/or Drawings:
❑ Yes ffNo ❑ NA ❑ NE
❑ Yes ER<o ❑ NA ❑ NE
❑ Yes
D o ❑ NA
❑ NE
❑ Yes
0411 ❑ NA
❑ NE
❑ Yes
La'No ElNA
ElNE
ElYes
��OEl NA
❑ NE
11/28/04

RIZ {",.k,. -"L & -/ f - z0 -o-7
W Division of Water Quality
Facility Number Q O Division of Soil and Water Conservation
Other Agency
Type of Visit ® Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit ® Routine O Complaint O Follow up O Referral O Emergency O Other ❑ Denied Access
Date of Visit:�p /%3_ -��d7 Arrival Time: $; 30 Departure Time: /O; UO County:
Farm Name: lAk L 6 z1_k �.S%1 Q� w 61t+yn/ Owner Email:
Owner Name: 1Jt6,bt.y- f -;x rz ri✓e. Phone:
Mailing Address:
Physical Address:
Region:
Facility Contact: Sp`^= �� u Uda Title: / a rbc 9 _ Phone No:
p
Onsite Representative: ScL+J ��. 4a o '� 0. 5 of la Integrator:��n �.. 6 L�dZ✓/✓
Certified Operator: Operator Certification Number:
Bach -up Operator:
Back-up Certification Number:
Location of Farm: Latitude: ❑ Q ❑ . ❑ Longitude: = o = I ❑ N
Swine
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
10-1La er
p Q ❑ Non -La ei
❑ Wean to Finish
5d No
Wean to Feeder
❑ NE
Feeder to Finish
ZDOC)
Farrow to Wean
7ZQ0 1300
El Farrow to Feeder
W No
❑ Farrow to Finish
❑ NE
El Gilts
JA No
El Boars
❑ NE
Other
❑ Other
Dry Poultry
❑ La ers
ElNon-Layers
El Pullets.
❑
Turkeys
❑ TurkeyPoults
❑ Other
Discharges & Stream Impacts
L Is any discharge observed from any part of the operation`?
Discharge originated at: [I Structure [I Application Field El Other
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
Design Current
Cattle Capacity Population
El Dairy Cow
El Dairy Calf
El Dairy Heifej
❑ D Cow
ElNon-Dairy
El Beef Stocker
El Beef Feeder
El Beef Brood Co
c. What is the estimated volume that reached waters of the State (gallons)?
Number of Structures: �'
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
El Yes rul
W No ❑ NA ❑ NE
❑ Yes
5d No
❑ NA
❑ NE
❑ Yes
�] No
❑ NA
❑ NE
❑ Yes
W No
[INA
❑ NE
❑ Yes
JA No
❑ NA
❑ NE
❑ Yes
V1 No
❑ NA
❑ NE
12/28/04 Continued

Facility Number: Q Date of Inspection
❑ Yes
[FNo
Waste Collection & Treatment
❑ NE
15. Does the receiving crop and/or land application site need improvement?
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
16 No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
No ❑ NA ❑ NE
T
Structure 1 Structure 2 Structure 3 Structure 4
Structure
5 Structure 6
Identifier:.01
5G !L.,Spillway?:
No
❑ NA
,,/`
o
18. Is there a lack of properly operating waste application equipment?
❑ Yes
Designed Freeboard (in):
❑ NA
❑ NE
w •/
Observed Freeboard (in): yq _ �Z
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
No ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on-site which are not properly addressed and/or managed
❑ Yes
No ❑ NA ❑ NE
through a 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 DWQ
7. Do any of the structures need maintenance or improvement?
❑ Yes
No ❑ NA ❑ NE
8. Do any of the stuctures 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/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below.
❑ Yes
RNo ❑ 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 Wi dow Evidence of Wind Drift ❑ Application Outside of Area
/❑
12. CroptYPe(s) O[f/.�t�tir4 �/�axt� - 574// '�(o-5� �vr�✓.
�1�.� ��tyj —
13. Soil type(s) C` , Le— At
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
[FNo
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?❑ Yes
No
❑ NA
❑ NE
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
Comments (refer to question ft Explain any YES answers and/or any recommendations or any other comments.
Use drawings of facility to better explain situations. (use additional pages as necessary):
Reviewer/Inspector Name T Phone: ` /*0, 4/33.3330
Reviewer/Inspector Signature: Date: w /.3 2007
12/2$/04 Continued

Facility Number: Q — Date of Inspection
Renuired Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available?
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
the appropriate box.
❑ WUP El Checklists El Design El Maps El Other
❑ Yes Qd No ❑ NA ❑ NE
❑ Yes [)4 No ❑ NA EINE
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes [P No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rain Inspections ❑ Weather Code
22. Did the facility fail to install and maintain a rain gauge?
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
24. Did the facility fail to calibrate waste application equipment as required by the permit?
25. Did the facility fail to conduct a sludge survey as required by the permit?
26. Did the facility fail to have an actively certified operator in charge?
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
and report the mortality rates that were higher than normal?
30. 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
31. Did the facility fail to notify the regional office of emergency situations as required by
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/Inspector fail to discuss review/inspection with an on-site representative?
33. Does facility require a follow-up visit by same agency?
Additional Comments and/or Drawings:
❑ Yes
No
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
❑ Yes
[A No
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
❑ Yes
1� No
❑ NA
❑ NE
❑ Yes
P No
❑ NA
❑ NE
❑ Yes q
No ❑ NA ❑ NE
❑ Yes �No ❑ NA ❑ NE
❑ Yes W No ❑ NA ❑ NE
❑ Yes W No ❑ NA ❑ NE
❑ Yes
�kNo
❑ NA
❑ NE
❑ Yes
q No
❑ NA
❑ NE
Page 3 of 3 12/28/04

Type of Visit A'Compliance Inspection U Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit:®// A Arrival//Time: /, 290 Departure Time:
�
Farm Name: tl e 6-z._r, Z <X 2,a Dw &Lwn r}'m
OwnerName:
Mailing Address:
Physical Address: ,/'
Facility Contact: �2 /a Z,% m e"S Title:
Onsite Representative: Y11
Certified Operator:
Back-up Operator:
i �Q County:- Region: 1 JC D
Owner Email:
Phone:
Phone No:
Integrator:
Operator Certification Number:
Back-up Certification Number:
Location of Farm: Latitude: [= o =' = Longitude: = ° = I =
11
1Hent DesignSwine pacity Pop�ulation�Poultry Capacity Popultion Cattle Capacity Populadan
❑ Wean to Finish F ❑ Layer ❑ Dairy Cow
Wean to Feeder I / DQ,0 -,rr-O JEJ Non -Layer I I ❑ Dairy Calf
Feeder to Finish Lo2ACC, I /&-D t7 7., ❑ Dai Heifer
Farrow to Wean D 7: " El D Cow
�Dry Poultry a
❑ Farrow to Feeder" M s ❑ Non -Dairy
❑ Farrow to Finish El La ers
❑ Beef Stocker
❑ Gilts, ❑Non -Lavers ❑ Beef Feeder
❑ Pullets
❑ Boars ��❑B eef Brood Co
❑
;a Turkeys
�`�� �� �,�
❑
Turkey Poults
❑ Other ❑OtherNumber of Structures:
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
2! -No
❑ 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 DWQ)
❑ Yes
❑ No
❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
❑ Yes
❑ No
❑ NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
XNo
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
J.No
❑ NA
❑ NE
other than from a discharge?
Page 1 of 3
12/28/04
Continued

Facility Number: —
r
Date of Inspection 6
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Structure 1n / Structure 2 Structure 3 Structure 4
Identifier: ', /4atxg t/ C z�i7 �C�iG'rk
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on-site which are not properly addressed and/or managed
through a waste management or closure plan?
❑ Yes [�-No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
❑ Yes JK No ❑ NA ❑ NE
❑ Yes RNo ❑ NA ❑ NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes KNo ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes JS 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 0 No ❑ NA ❑ NE
maintenance or improvement?
Waste Avolication
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes ,® No ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes 0 No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or I 0 lbs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
12. Crop type(s) [ _ar'Yt �W�r � �', a�5/ lYllkpfa� /®yr/�t71/� (5y"10!:0 f
Comments (refer to question ##): Explain any YES answers and/or any recommendations or any -other comments.
Use drawings of facility to better explain situations. (use additional pages as necessaryj:
Reviewer/Inspector Name
Reviewer/Inspector Signature:
Page 2of3
Phone: D- O O
r Date: A 7 -:;-,?t)D6
12/28/04 Continued
13.
Soil type(s) r!_4 le I-
14.
14.
Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
&No
❑ NA
❑ NE
15.
Does the receiving crop and/or land application site need improvement?
❑ Yes
9 No
❑ NA
❑ NE
16.
Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
[:]Yes
JZ No
❑ NA
❑ NE
17.
Does the facility lack adequate acreage for land application?
❑ Yes
JO No
❑ NA
❑ NE
18.
Is there a lack of properly operating waste application equipment?
❑ Yes
J�g No
❑ NA
❑ NE
Comments (refer to question ##): Explain any YES answers and/or any recommendations or any -other comments.
Use drawings of facility to better explain situations. (use additional pages as necessaryj:
Reviewer/Inspector Name
Reviewer/Inspector Signature:
Page 2of3
Phone: D- O O
r Date: A 7 -:;-,?t)D6
12/28/04 Continued

Facility Number: — Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes N No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes 1EINo ❑ NA ❑ NE
the appropriate box. ❑ WUP ❑ Checklists ❑ Design ❑ Maps ❑ Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes ER No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rain Inspections ❑ Weather Code
22. Did the facility fail to install and maintain a rain gauge? - ❑ Yes EdNo ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes Jallo ❑ NA ❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
J9 No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
§Q No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
JZ No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
JZ No
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
allo
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
IM No
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30.
At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
J0 No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
31.
Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
$4 No
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on-site representative?
❑ Yes
El No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
R No
❑ NA
❑ NE
Additional Comments and/or Drawings:
Page 3 of 3 12/28/04

Type of Visit (!7 Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit 0 Routine 0 Complaint Q Follow up 0 Referral 0 Emergency Q Other ❑ Denied Access
Date of Visit: j//—0t5- Arrival Time: Departure Time: D Countv: ��R�i'r� Region: `
Farm Name: / /Cee- � � &� C Owner Email:
Owner Name: jwwx/r-r /hem's T yy Phone[::
Mailing Address: �s0• Qk f'D8'? - - -- i'! ...4� lT�-�� %�� - -
Physical Address: T 1f:�
Facility Contact: I/&_mt { e Z Title: Phone No: 9��`o26.Z-7��f✓�S
Onsite Representative: // Integrator:
Certified Operator: l% Operator Certificaon Number:
Back-up Operator:
Back-up Certification Number:
Location of Farm: Latitude: =0 0' 0 « Longitude: =° =, ❑
gs
Swine
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer Q (P �D ❑ Non -Layer
❑ Wean to Finish
ZNo
.Wean to Feeder
❑ NE
CO Feeder to Finish
Dao J'0 O
Farrow to Wean
%, 9 DO 7"0
❑ Farrow to Feeder
No
[3 Farrow to Finish
❑ NE
El Gilts
� No
El Boars
❑ NE
Other
❑ Other
Dry Poultry
❑
Layers
❑
Non -Layers
❑ Pullets
❑
Turkeys
El Turkey s
Poult
❑ Other
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: El Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
Design Current;.`
Cattle Capacity Population. -
0 Dai Cow
❑ Dai Calf
El Dairy Heifer
E:1 Dry Cow
ElNon-Dairy
El Beef Stocker
❑ Beef Feeder
❑ Beef Brood Cowl
c. What is the estimated volume that reached waters of the State (gallons)?
Number of Structures:
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
i
❑ Yes RNo ❑ NA ❑ NE
❑ Yes
ZNo
❑ NA
❑ NE
❑ Yes
®,No
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
El Yes
� No
❑ NA
❑ NE
❑ Yes
� No
El NA
[:1 NE
12/28/04
Continued

._;.
12. Croptype(s) �>vrl�,t K t,'If�T�far.K �' f��klhr_�� ybyerws
Facility Number: — Date of Inspection
1�►YtG.�S
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
P -No ❑ NA ❑ NE
Structure I Structure 2 Structure 3 Structure 4
Structure
5 Structure 6
I
Identifierr
:?
❑ NA
❑ NE
Spillway?:
[:1 Yes
C -No
Designed Freeboard (in):
❑ NE
17. Does the facility lack adequate acreage for land application?
Observed Freeboard (in): 31-) a
®.No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
;KNo ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on-site which are not properly addressed and/or managed
❑ Yes
§9 No ❑ NA ❑ NE
through a 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 DWQ
7. Do any of the structures need maintenance or improvement?
❑ Yes
KNo ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit?
❑ Yes
KNo ❑ 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
20'4 No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
0 N ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect 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 Area ,
12. Croptype(s) �>vrl�,t K t,'If�T�far.K �' f��klhr_�� ybyerws
�3f~/JI?
1�►YtG.�S
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
[KNo
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
RNo
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination,
[:1 Yes
C -No
❑ NA
❑ NE
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
rM No
[:]NA
❑ NE
Comments (refersto question #) Eaplainrany YES aaswers aQ�or any recommendations or any other comments.
Use drawings affactLtytobetter explamisrivahons.'(ase additronai pages as necessary):
Reviewer/Inspector Name Phone: lK�
Reviewer/inspector Signature: Date: Z/ZZQs
12/28/04 Continued

23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes 9No ❑ NA ❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
10 No
❑ NA
Facility Number: — Date of Inspection
25. Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
19 No
Required Records & Documents
❑ NE
26. Did the facility fail to have an actively certified operator in charge?
❑ Yes
19. Did the facility fail to have Certificate of Coverage & Permit readily available?
❑ Yes
0 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 appropirate box.
❑ WUP [:1 Checklists [:1 Design El Maps El Other
21. Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
9 No
❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1"
Rain Inspections ❑
Weather Code
22. Did the facility fail to install and maintain a rain gauge?
❑ Yes
® No
❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes 9No ❑ NA ❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
10 No
❑ NA
❑ NE
25. Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
19 No
❑ NA
❑ NE
26. Did the facility fail to have an actively certified operator in charge?
❑ Yes
5d No
❑ NA
❑ NE
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
;K No
❑ NA
❑ NE
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
Z No
❑ NA
❑ NE
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
23 No
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
[N No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
31. Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
J9 No
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/Inspector fail to discuss review/inspection with an on-site representative?
❑ Yes
®No
❑ NA
❑ NE
33. Does facility require a follow-up visit by same agency?
❑ Yes
§Q No
❑ NA
❑ NE
,"&t inial Co i ments;andlor-Drawings
11118104
11118104

Type of Visit @►Compliance Inspection O Operation Review O Lagoon Evaluation
for Visit Q Routine Q Complaint O Follow up O Emergency Notification O Other ❑ Denied Access
Facility Number Date of Visit: �oy Time:.©D
Q Not Operational Q Below Threshold
31 Permitted ® Certified 13 Conditionally Certified 13 Registered Date Last Operated or Above Threshold• _
Farm Name: S I Z+�st tia-1ca+v%.;W c, b b c v, _ County: Q 1 a oQ c n
Owner Name: ' Phone No:
Nb icing Address: �PO • x 1 G 9 T A2 -) C-
Facility Contact: Y w.► Ytyuczc Title:
Phone No:
Onsite Representative: _ _ _ __- _ Integrator. Mu o * - �2 C.p 9-1 r)
Certified Operator: SQ«.�-i ay R, Ya A iuc ir= Operator Certification Number.,, 7d,_
Location of Farm:
Swine ❑ Poultry ❑ Cattle ❑ Horse Latitude Longitude �• I�'JK
Disc es & Stream Lnaacts
1. Is any discharge observed from any part of the operation? ❑ Yes .® No
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man -trade? ❑ Yes ❑ No
b. If discharge is observed, did it mach Water of the State? (If yes, notify DWQ) ❑ Yes ❑ No
c. If discharge is observed, what is the estimated flow in gal/min? HIA
d. Does discharge bypass a lagoon system? (If yes, notify DWQ) ❑ Yes ❑ No
2. Is there evidence of past discharge from any part of the operation? ❑ Yes ® No
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes ® No
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway ❑ Yes IM No
Structure i Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:_ -
Freeboard (inches):
12112103 Continued

Fa,lity Number: 9 • — L�/ Date of Inspection !o /,-/ay
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, ❑ Yes ® No
seepage, etc.)
6. Are there structures on-site which are not properly addressed and/or managed through a waste management or ❑ Yes] No
closure plan?
(If any of questions 4-6 was answered yes, and the situation poses an
immediate public health or environmental threat, notify DWQ)
7. Do any of the structures need maintenance.Tunprovement? ❑ Yes (j@ No
8. Does any part of the waste management system other than waste structures require mamtenanceJimprovement? ❑ Yes ® No
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level ❑ Yes ® No
elevation markings?
Waste Application
10. Are there any buffers that need maintenance/improvement? ❑ Yes ® No
11. Is there evidence of over application? If yes, check the appropriate box below. ❑ Yes ® No
❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload ❑ Frozen Ground ❑ Copper and/or Zinc
12. Crop type Q�//)'l/lsa�a �.er� /S�rny�ee{�Q .cvn?�dd�� sG //�et� Gte� Yo�a�ioa] �Lpfr.`ca:►rsf, Saf��agH.
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)? ❑ Yes ® No
14. a) Does the facility lack adequate acreage for land application?
b) Does the facility need a wettable acre determination?
c) This facility is pended for a wettable acre determination?
15. Does the receiving crop need improvement?
16. Is there a lack of adequate waste application equipment?
Odor Issues
17. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below
liquid level of lagoon or storage pond with no agitation?
18. Are there any dead animals not disposed of properly within 24 hours?
19. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt,
roads, building structure, and/or public property)
20. 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.
❑ Yes ® No
❑ Yes ® No
❑ Yes W No
❑ Yes ® No
❑ Yes ® No
❑ Yes P No
❑ Yes ® No
❑ Yes M No
❑ Yes 9No
12/I2/03 . U
cUse dr�wYa�s o!'fae�ty to�betbtt e�cpl�n s's�ba.�{nae a�ea�ai p�es.skc k Field C Final Notes ��
ReviewerAhspector Name� =
_
Reviewer/Inspector Signature: Date:
12/I2/03 . U

Facility ]lumber: Date of Inspection
Required Records & Documents
21. Fail to have Certificate of Coverage & General Permit or other Permit readily available?
❑ Yes
❑ No
22. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
�
l4R000, Ic�ci iv�spnc.'�tart
(ie/ WUP, checklists, design, maps, etc.)
❑ Yes
No
23. Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
No
❑ Waste Application ❑ Freeboard ❑ Waste Analysis ❑ Soil Sampling
24. Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
® No
25. Did the facility fail to have a actively certified operator in charge?
❑ Yes
[B No
26. Fail to notify regional DWQ of emergency situations as required by General Permit?
H
(ie/ discharge, freeboard problems, over application)
❑ Yes
(jj No
27. Did Reviewer/inspector fail to discuss reviewimspection with on-site representative?
❑ Yes
® No
28. Does facility require a follow-up visit by same agency?
❑ Yes
® No
29. Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
No
NTPDES Permitted Facilities
34. Is the facility covered under a NPDFS Permit? (If no, skip questions 31-35)
50 Yes
❑ No
31. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
r] Yes
IM No
32. Did the facility fail to install and maintain a rain gauge?
❑ Yes
11 No
33. Did the facility fail to conduct an annual sludge survey?
❑ Yes
® No
34. Did the facility fail to calibrate waste application equipment? ❑ Yes ® No
35. Does record keeping for NPDES required forms need improvement? If yes, check the appropriate box below. ❑ Yes ❑ No
❑ Stocking Form ❑ Crop Yield Form ❑ Rainfall ❑ Inspection After 1" Rain
❑ 120 Minute Inspections ❑ Annual Certification Form
113 No violations or deficiencies were noted dining this visit. You will receive no further correspondence about this visit.
Y---
�'..;.
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�
l4R000, Ic�ci iv�spnc.'�tart
FCSw� W0. i r.•.��. ►^� 14ItSw�+
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r� tPo4's a +oac• yb4L— 1rto�` k CC -A
G�.-uvG GycCG�tiv� 'fFae� �eM+. 5L+ad2ew �oRcr.r. �nfoe.,.
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l2/I2/03