090169_INSPECTIONS_20171231

NORTH CAROLINA
Department of Environmental Qual

I ision of Water Quality
i�'acilit�y Number Division of Soll and Water Conservation
it
A gene
g Y
Type of Visit' 0 Compliance Inspection 0 Operation Review uc ure Evaluation 0 Technical Assistance
Reason for Visit 0 Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency Other ❑ Denied Access
Date of Visit: f-- O Arrival Time: 10 : ti Departure Time: 1 County: .- Region: Yf�90
Farm Name: �+� r '-•� Owner Email:
Owner Name:- szat_t_ _ _ Phone:
Mailing Address: _
Physical Address:
Facility Contact: _
Onsite Representative:
Certified Operator: _
Back-up Operator: _
Location of Farm:
Title:
Latitude:
n°
Phone No:
Integrator:
Operator Certification Number:
Back-up Certification Number:
Longitude: E-1 ° E-1 d =
11re-si—MR11000rrent Design
Swine Capacity Population Wet Poultry Capacity
Current
Population
Cattle
Design
C+apacity
C►urrent
Population
❑ Wean to Finish
❑ Layer
I
❑ Daia Cow
❑ Wean to Feeder
1
10 Non -Layer I
I
❑ Dairy Calf
❑ Feeder to Finish
Dry Poultry
El Layers
❑ Dairy Heifer
❑ Dry Cow
ElNon-Dai
❑ Beef Stocker
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Non -Layers
❑ Beef Feeder
❑ Boars
❑ Pullets
El Beef Brood Cow
Other
El Turke s
❑ Turkey Poults
❑ Other
Number of Structures:
❑ Other
Discharges & 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 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 [51TE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
❑ No
❑ NA
D-NE
❑ Yes
❑ No
❑ NA
C:j`NE
Page 1 of 3
12128104 Continued

Facility Number: Date of Inspection
Waste Collection & Treatment
4. is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes ❑ No ❑ NA [TIE
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:
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 2-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 f7 '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 2-NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes ❑ No ❑ NA ONE
(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 EINE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes ❑ No ❑ NA M NE
maintenance/improvement?
'01-
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes ❑ No ❑ NA [?�E
❑ 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
❑ No
❑ NA
[]-RE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
❑ No
❑ NA
C NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
❑ Yes
❑ No
❑ NA
EJ"NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
❑ No
❑ NA
[2-NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
❑ No
❑ NA
O-NE
Comments (refer to question.:#!) .Explain any YES answernd/ s aor any recommendations or any other comments'
Usedrawings offacillty ta,better explain situations.(use additional pages'as necessary)bz,
Reviewer/inspector Name I-i.-t Phone:
Reviewer/Inspector Signature: Date: D 19af--l-41 = I j
Page 2 of 3 1V-1d/V4 uonnnuea

Facility Number: Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes ❑ No ❑ NA `ENE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes ❑ No ❑ NA NE
the appropriate box. ❑ WUP ❑ Checklists ❑ Design El Maps ElOther
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes ❑ No ❑ NA E5ICE
❑ 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
©TT
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
❑ No
❑ NA
E} NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
❑ No
❑ NA
ffNE
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
ONE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
❑ No
❑ NA
B NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
❑ No
❑ NA
E311�E
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
El Yes
❑ No.
❑ NA
I3NE
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
EKE
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
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
[J"NE
Additional Comments:and/or Drawings:
Page 3 of 3 12128104

May 19, 2010
Mr, Steve Guyton
NCDENR/Division of Water Quality
225 Green St., Suite 714
Fayetteville, NC 28301
Dear Mr. Guyton:
Please be advised that my lagoon level (Facility 09-169) came back into compliance on
Moreh .2C%.. 2010 and remains in compliance on this date.
Sincerely,
Charles Gillespie
874 Dewitt Gooden Rd.
Elizabethtown, NC 28337

`ED Division of Water Resources
i Facility Number 0 Division of Sol] and Water Conservation
0 Other Agency
Type of Visit: Corn ' cc Inspection Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: CrRoutine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: 70 a Departure Time: County: Region:
Farm Name:
Owner Name: C�j(�/ f. S t�i f l S yf, 1=
Mailing Address:
Physical Address:
Owner Email:
Phone:
Facility Contact: ('&�/4�y ii %lz'�~t Title:Phone:
Onsite Representative: Integrator: ..
Certified Operator: Certification Number:
Back-up Operator: Certification Number:
Location of Farm:
Swine
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Boars
Other
Other
Latitude:
Design Current Design Current
Capacity Pop. Wet Poultry Capacity Pop.
Layer
Non -La er
Dry Poultry
Layers
Non -Layers
Pullets
Turkeys
Turkey Poults
Other
Design Current
Discharees 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)?
Longitude:
Design Current
Cattle Capacity Pop.
Dairy Cow
Dairy Calf
Dairy Heifer
Dry Cow
.Non -Dairy
Beef Stocker
Beef Feeder
Beef Brood Cow
❑ Yes � No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
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 RNo ❑ NA ❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to,the waters ❑ Yes JD_No ❑ NA ❑ NE
of the State other than from a discharge?
Page 1 of 3 21412015 Continued

lFacility Number: - Z jDate of Inspection:
Waste Collection &'Treatment
ol
' 4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
M 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):
Observed freeboard (in): 4�z
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
IVI No
❑ NA
❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a
❑ Yes
No
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health
or environmental
threat,
notify DWR
7. Do any of the structures need maintenance or improvement?
❑ Yes
F�jNo
❑ 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.
J&No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
C5No
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes j2jNo ❑ 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 Drill ❑ Application Outside of Approved Area
x �J
12. Crop Type(s): ira60eZV/berq r-
/
13. Soil Type(s):
14.
Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
K No
❑ NA
❑ NE
15.
Does the receiving crop and/or land application site need improvement?
❑ Yes
XNo
❑ NA
❑ NE
16.
Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
allo
❑ NA
❑ NE
acres determination?
17.
Does the facility lack adequate acreage for land application?
❑ Yes
RNo
❑ NA
❑ NE
18.
Is there a lack of properly operating waste application equipment?
❑ Yes
ZNo
❑ NA
❑ NE
Required
Records & Documents
19.
Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
A No
❑ NA
❑ NE
20.
Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
O'No
❑ NA
❑ NE
the appropriate box.
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement'? If yes, check the appropriate box below. ❑ Yes ;No
❑ 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 R.No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? [:]Yes EDN o
❑NA ❑NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
[]NA ❑NE
Page 2 of 3 21412015 Continuer)

Facility Number: - Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes g-No
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes [0 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 provide documentation of an actively certified operator in charge? ❑ Yes 10 No
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes EKNo
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
34. Does the facility require a follow-up visit by the same agency?
❑NA ❑NE
❑ NA ❑ NE
❑NA ONE
❑ NA ❑ NE
❑ Yes CZ -No ❑ NA ❑ NE
❑ Ycs 2-No ❑ NA ❑ NE
[-]Yes 2� No ❑ NA ❑ NE
❑ Yes C,No ❑ NA [] NE
❑ Yes
12SLNo
❑ NA
❑ NE
❑ Yes
.0 No
❑ NA
❑ NE
❑ Yes
[�No
❑ NA
❑ NE
Commett_ts (refei-to�questio� #) Explain gny YES answersand/oriany, additiooairecammendationsxor uny other comments
... ,-rt�-. ..�z a¢ ?'a �...;M.
Usc drawings of facili';.to�kietter.explainaitu`i3tionsp(use{additional ages as, necessary) .i
Reviewer/Inspector Name:
Reviewer/Inspector Signatui
Page 3 of 3
Phone: Z23 --
Date:
21412015

!� Type of Visit: ompliance Inspection 0 Operation Review Q Structure Evaluation O Technical Assistance
Reason for Visit: outine O Complaint O Follow-up O Referral 0 Emergency O Other O Denied Access
Date of Visit: —/ Arrival Time: Departure Time: l%c County: Region:
Farm Name: � /4-6 Qi m /-0 Owner Email:
Owner Name: jo/'ltas [(/ �;'%GS,�i` r� Phone:
Mailing Address:
Physical Address:
Facility Contact:Title: Phone:
�'� Phone:
Onsite Representative: Integrator: A5 jy'
Certified Operator: Certification Number:
Back-up Operator:
Location of Farm:
Latitude:
Certification Number:
Longitude:
Design Current
Design
Current
esign Current
Swine Capacity Pop.
Wet ,Poultry
ut clty
Pop.
Cattlewelapacity Pop.
Wean to Finish
La er
al Cow
Wean to Feeder
Non -La er
airy Calf
Feeder to Finish
pG 0o
Dai Heifer
Farrow to Wean
Design
Current
D Cow
Farrow to Feeder
0 . $oult ,
Ca .aci
P■o
Non -Dairy
Farrow to Finish
Layers
Beef Stocker
Gilts
Non -La ers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turkeys
Other
Turke Poults
10ther
M—FlOther
Discharees 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 C�J_No ❑ NA [:]NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes []No
❑ Yes [2�No
❑ Yes ac No
❑ NA ❑ NE
❑ NA [] NE
❑ NA ❑ NE
Page 1 of 3
21412014 Continued

Facili Number: - Date of Ins eetion: G
" 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:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
JZ 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
allo
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health
or environmental threat,
notify DWR
7. Do any of the structures need maintenance or improvement?
❑ Yes
["No
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
MNo
❑ 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
Q No
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes E5-No ❑ NA ❑ NE
❑ Excessive Ponding 0 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): ��eflUlfldc
13. Soil Type(s); f
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 No ❑ NA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
t8. Is there a lack of properly operating waste application equipment?
❑ Yes VX11 ❑ NA ❑ NE
❑ Yes 23-No ❑ NA ❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes No ❑ NA ❑ NE
the appropriate box.
❑ WUP [3 Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes allo
❑ 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 fait to install and maintain rainbreakers on irrigation equipment? ❑ Yes [ E No
❑NA ❑NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 21412014 Continued

Facili Number: - b Date of Inspection:
' 24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes MNo
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 allo
27. Did the facility fail to secure a phosphorus loss assessments (PLAT") certification? ❑ Yes CE 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.
0 Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
33. Did the ReviewerlInspector 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 [D No ❑ NA ❑ NE
❑ Yes �o ❑ NA ❑ NE
[]Yes allo ❑ NA ❑ NE
® Yes o ❑ NA ❑ NE
[:]Yes
® No
[] NA
❑ NE
❑ Yes
� No
❑ NA
❑ NE
❑ Yes
ZNo
❑ NA
❑ NE
Comments (refer to,question #): Explain any,YES answers and/or an additional recommendatlons opanmther comments.,
> � = I a . gin,
iTse+drawings of facility to beftet explain`situations (use additional pages°as necessary) ': x , ,: „k ' a
° zt-
� v
✓`�°r7�r`�
ReviewerlInspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone:
Date:
21412014

03
F
Type of Visit: OTompliynce Inspection U Operation Review O Structure Evaluation O Technical Assistance I
Reason for Visit: Q,1outine 0 Complaint 0 Follow-up O Referral O Emergency 0 Other 0 Denied Access
Date of Visit: j;j—__.4T Arrival Time: ; D D Departure Time: i O County:
Farm Name: /ji //,!Sbi ri Far,ns Owner Email:
if
Owner Name: �'drF'�,rS fit% �Si f��jbi�r Phone:
Mailing Address:
Physical Address:
Facility Contact: r' ,� rdl ��� Il p� Title: BC(JYIr-1- Phone:
dr
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Region: ��
Integrator:
Certification Number:
Certification Number:
Longitude:
Design Current
Design
Current
Design
Current
Swine Capacity Pop.
Wet Poultry
Capacity
Pop.
@attic Capacity
Pop.
Wean to Finish
ayer
RL
Dai Cow
Weto Feeder
Dai Calf
Feeder to Finish
pp
Dai Heifer
Farrow to Wean
Design
Current
D Cow
Farrow to Feeder
Dr P,oultr,
C•.a aci
P,o
Non -Dairy
Farrow to Finish
La ers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turke s
Other
TurkeyPoults
Other
Other
Discharees 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
❑ Yes ® No
[:]Yes ® No
❑NA ❑NE
❑ NA ❑ NE
❑ NA ❑ NE
Page 1 of 3 21417014 Continued

Facility Number: - Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes 5? No
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No
Identifier:
❑ NA ❑ NE
❑ NA ❑ NE
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):�
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes M 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
[3 NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health
or environmental threat,
notify DWR
7. Do any of the structures need maintenance or improvement?
❑ Yes
No
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
No
❑ NA
❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require
❑ Yes
No
❑ NA
❑ NE
maintenance or improvement?
Waste Apmlication
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
Z�No
❑ NA
❑ NE
maintenance or improvement?
11. is there evidence of incorrect land application? 1f yes, check the appropriate box below.
❑ Yes
Z_No
❑ NA
❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 101bs. ❑ 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): ZZ7-mu'/4 / ®t/es✓�, �
13. Soil Type(s): r / %i "ta •
tr
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
[S No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
[5? 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?
IT Does the facility lack adequate acreage for land application?
❑ Yes
® No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
® No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
® No
❑ NA
[] NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
® No
❑ NA
❑ NE
the appropriate box.
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? if yes, check the appropriate box below. ❑ Yes g 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 ® No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑NA ❑NE
Page 2 of 3 21412014 Continued

Facility Number: q - Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes [gNo
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes El 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 la No
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes fo 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.
❑ 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 Q No ❑ NA ❑ NE
❑ Yes M[ No ❑ NA ❑ NE
[—]Yes 2 No [] NA ❑ NE
❑ Yes 54 No ❑ NA ❑ NE
❑ Yes
® No
❑ NA
❑ NE
❑ Yes
�R No
❑ NA
❑ NE
[] Yes
JZ 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):
0
Reviewer/Inspector Name:
ReviewerlInspector Signature;
Page 3 of 3
Phone:
Date:
21412014

4
ivision of Water Quality
Facility Number - © O Division of Soil and Water Conservation I
O Other Agency
Type of Visit: ompliance Inspection 0 Operation Review Q Structure Evaluation Q Technical Assistance
Reason for Visit: 016utine O Complaint O Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit: Arrival Time: Departure Time: _071 D !7 County: �--_
Farm Name: /-e,S Pz_ C'FivrYtS _ _ Owner Email:
Owner Name: ,4a✓` JYS w &,, I j r, C-- Phone:
Mailing Address:
Physical Address: �s
Facility Contact: B�IYf I Title: O-W IL t- r— Phone:
Onsite Representative: -5_'_ .._
Certified Operator:
Back-up Operator:
Location of Farm:
Swine
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Other
Other
Latitude:
Region: /--)ZQ
Integrator:Imi.<,04
Certification Number: Al
Certification Number:
Design Current Design Current
Capacity Pop. Wet Poultry Capacity Pop.
"Layer
Non -La er
Non -
Other
Poults
Design Current
Yo
Discharees 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?
Longitude:
Design Current
Cattle Capacity Pop.
Dairy Cow
Dairy Calf
Dairy Heifer
Dry Cow
Non -Dairy
Beef Stocker
Beef Feeder
Beef Brood Cow
❑ Yes 2],No ❑ NA ❑ NE
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes 1- No
❑ Yes �.No
❑NA ❑NE
❑ NA ❑ NE
❑ NA ❑ NE
❑NA ❑NE
❑ NA ❑ NE
Page I of 3 21412011 Continued

Facility Number: - 14, Date of Inspection: 7
Waste Collection & Treatment
L 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 ❑ No ❑ NA ❑ NE
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
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.)
❑ Yes [S�No ❑ NA ❑ NE
6. Are there structures on -site which are not properly addressed and/or managed through a
❑ Yes
[2,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
U No
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
RNo
❑ 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
ENo
❑ 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):,,t Qv �►t•-d
13. Soil Type(s):
14. Do the receiving crops differ from those designated n the CAWMP?
15. Does the receiving crop and/or land application site need improvement?
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
the appropriate box.
❑ Yes �No
❑ Yes �, No
❑ Yes 5a No
❑ Yes ® No
❑ Yes RLNo
[—]Yes No
[] Yes No
❑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 1" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes 0 No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes E. N
❑NA ❑NE
❑ NA ❑ NE
❑NA ❑NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑NA ❑NE
❑NA ❑NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
o ❑ NA ❑ NE
Page 2 of 3 21412011 Continued

Facility Number: 1 Date of Inspection: —
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes gj No ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes P 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 L&No ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes R No ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
[. No
❑ NA
❑ NE
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
UgNo
❑ 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
R No
❑ NA
❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface the drains exist at the facility? If yes, check the appropriate box below.
❑ Yes
INo
❑ 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
® No
❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
QjNo
❑ NA
❑ NE
Comments (refer to question ft Explain any YES answers and/or any additional recommendations or any other comments.
Uwdrhwings of facility to better ex lain situations (use additional pages as necessary).
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: TOO
Date:
21412011 ,

LrDivision of Water Quality �f fT� ✓
Facility Number - ® O Division of Soil and Water Conservation ra-i-
Q Other Agency
Type of Visit: Compliance Inspection 0 Operation Review Q Structure Evaluation Q Technical Assistance
Reason for Visit: outine O Complaint O Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit: LLB LaG��J Arrival Time: pQ Departure Time: :OD County: �� ..
Farm Name: ! 'e i & u/ Owner Email:
Owner Name: T-i7 �.� %r5 l'(.j�T Phone:
Mailing Address:
Physical Address:
Facility Contact: ahw-]�ri GU(-��I e' ;t Title: J%00r,r Phone:
Onsite Representative: Integrator:
Certified Operator: Certification Number:
Back-up Operator: Certification Number:
Location of Farm: Latitude: Longitude:
Swine
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feedei
Farrow to Finish
Gilts
Other
Other
Design Current Design Current
Capacity Pop. Wet Poultry Capacity Pop.
RL'
er
n-La er
Pullets
Other
Poults
Design Current
Dischar es 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?
Region:
Design Current
Cattle Capacity Pop.
Dairy Cow
Dairy Calf
Dairy Heifer
Dry Cow
.Non -Dairy
Beef Stocker
Beef Feeder
Beef Brood Cow
❑ Yes Wo ❑ NA ❑ NE
❑Yes ❑No ❑NA [3 NE
❑ Yes [] No ❑ NA ❑ NE
❑ Yes ❑ No
[:]Yes C.No
[:]Yes 0 No
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Page I of 3 21412011 Continued

Facili Number: - Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequatc?
[]Yes
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):
Observed Freeboard (in):�
5. Are there any immediate threats to the integrity of any of the structures observed?
[]Yes
No
❑ NA
❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a
❑ Yes
'® No
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat,
notify DWQ
7. Do any of the structures need maintenance or improvement?
❑ Yes
2�No
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
UNo
❑ 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
ER -No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
[] Yes
[a No
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes N 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): QCY797 /t>r�iY'�2�
13. Soil Type(s): y�,_
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
PRNo
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
&No
❑ NA
❑ NE
W Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
�R No
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
MNo
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
54�No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
5Z No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
GS 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 M No ❑ 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 fait to install and maintain rainbreakers on irrigation equipment? ❑ Yes Wo ❑ NA ❑ NE
Page 2 of 3 21412011 Continued

Facility Number: - Date of inspection:
* 24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes [B No
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes ANo
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 [KNo
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes R 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.
❑ 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 21 No [3 NA [] NE
❑ Yes 5kNo ❑ NA ❑ NE
[] Yes ®.No ❑ NA ❑ NE
[:]Yes RNo ❑ NA ❑ NE
❑ Yes [� No ❑ NA ❑ NE
❑ Yes 0 No ❑ NA [3 NE
❑ Yes fia No ❑ NA ❑ NE
CoFnments (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:I.� fl.�
21412011

C) Division of Water Quality C.—
Facility Number ®- F_Zl7' 0 Division of Soil and Water Conservation
0 Other Agency
Type of Visit: EMompliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: a','DC7 Departure Time: County: �w
Farm Name: Owner Email:
:�/
Owner Name: 44/'��s Ael. e,An%r, e- Phone:
Mailing Address:
Physical Address:
Region:
Facility Contact: 4!2,�s s pT� Title: ,C�[yfj�� Phone:
v
Onsite Representative: Integrator:f�/d
Certified Operator: i��..L.� Certification Number:
Back-up Operator:
Location of Farm:
Design Current
Swine Capacity Pop.
Wean to Finish
Wean to Feeder
Feeder to Finish pU p
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Boars
Other
Other
Certification Number:
Latitude:
Design Current
Wet Poultry Capacity Pop.
Layer
Non -La er
ury rouit
Non-L
Pullets
Turkey Pouets
Other
Design Current
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)
e. What is the estimated volume that reached waters of the State (gallons)?
Longitude:
Design Current
Cattle Capacity Pop.
Dairy Cow
Dairy Calf
Dairy Heifer
Dry Cow
Non -Dairy
Beef Stocker
Beef Feeder
Beef Brood Cow
❑ Yes [0 No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
- ❑ NA
❑ NE
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
CD No
❑ NA
❑ NE
❑Yes
®No
❑NA
❑NE
Page 1 of 3 21412011 Continued

liacilit Number: - Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate'?
❑ Yes
® No
❑ NA
❑ NE
a. I f 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:
Spillway?:
Designed Freeboard (in):
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
[" 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
1�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
rtA No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
kaNa
❑ 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): nr,,2ru
13. Soil Type(s): �f/u�6ar- / 6t
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
[Z No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
0 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?
❑ Yes
allo
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
BNo
❑ NA
❑ NE
Reuuired Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
R-A No
[] NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
P5,No
❑ NA
❑ NE
the appropriate box.
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes ® No
❑ 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 lZ No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? [] Yes ®.N
❑ NA ❑ NE
0 Weather Code
❑ Sludge Survey
❑ NA ❑ NE
o []NA ❑NE
Page 2 of 3 214120.11 Continued

Y
Facili Number: jDate 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 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 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 E] 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 Officc 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/[nspector 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 M No ❑ NA ❑ NE
❑ Yes 7'No ❑ NA ❑ NE
❑ Yes r'5:rNo ❑ NA ❑ NE
❑ Yes ® No ❑ NA ❑ NE
❑ Yes
� No
❑ NA
❑ NE
❑ Yes
® No
❑ NA
❑ NE
[:]Yes
No
❑ NA
❑ NE
Comments (refer to question #):Explain any YES answers aad/or any additional recommendations or any;other comments.
Use drawings of facility to better explain situations (use additional ages as necessary).
Reviewer/inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone:
Date:
2/4/2011

Type of Visit Q)<55mpliance Inspection O Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit Gr outine O Complaint O Follow up O Referral O Emergency O Other ❑ Denied Access
Date of Visit: /L Arrival Time: . 3 r7 Departure Time: 13 (D County: .rw Region: .f.'WO
Farm Name: v f 1 r� QreK Owner Email:
Owner Name: d r' �,— i fit r•a/�% t' Phone:
Mailing Address:
Physical Address:
Facility Contact: / *' Title: Phone No:
Onsite Representative: " ! Integrator: /
Certified Operator: S� Operator Certification Number:
Back-up Operator:
Back-up Certification Number:
Location of Farm: Latitude: = o = 4 ❑ Longitude: ❑ o 0 ` =
Design Curr
IDegign Current
sign Current
DlVIPODUlFtiOnT
Swine
et Poultry Cap)aefty Population
Cattle
Caacit❑
Wean to Finish
a er
❑ Dai Cow
❑ Wean to Feeder
Non -Layer
❑ Dairy Calf
JZ Feeder to Finish
❑ Daisy Heiler
❑ Farrow to Wean
Dry Poultry
❑ Dry Cow
❑ Farrow to Feeder
ElNon-Dairy
El Farrow to Finish
El Layers
[3 Stocker
El Gilts
El Non-Layers
El
El Beef Feeder
El Boars
El Pullets
❑Beef Brood Cow
❑ Turkeys
Other
❑Turke Poults
❑ Other
❑Other
Number of Structures:
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
EgNo
❑ 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
No
❑ NA
❑ NE
other than from a discharge?
Page I of 3
12128104
Continued

Facility Number: Date of Inspection(
1
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 l Structure 2 Structure 3 Structure 4
Identifier:
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 �9 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 9No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes [5�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 ffNo ❑ 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 MNo ❑ 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 El Application Outside of Area
12. Crop type(s) 7&,—ia�C.s ��,��5� .-�✓
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
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?[] Yes
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
❑ Yes
❑ Yes
No
M-No
01 No
�F-No
El NA ❑NE
❑NA ❑NE
❑ NA ❑ NE
❑ NA ❑ NE
Reviewer/Inspector Name Phone: c
Reviewer/Inspector Signature: Date: --
Page 2 of 3 12128104 Continued

_ Facility Number: - 9 Date of Inspection
+I
Reuuired 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
RNo
❑ NA
❑ NE
the appropirate box. ❑ WUP ❑ Checklists ❑ Design ❑ Maps ❑ Other
21. Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
Dallo
❑ 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
(XNo
❑ NA
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes 9 No ❑ NA ❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
R 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
C.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
Z No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
9 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
P9.No
❑ NA
❑ NE
Additional.Commen'ts and/or 9idW n65.'
w
Page 3 of 3 12128104

Division of Water Quality
Facility Number 0 Division of Soil and Water Conservation
0 Other Agency
�
Type of Visit O'Co—mpliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit tine Q Complaint 0 Follow up 0 Referral 0 Emergency Q Other ❑Denied Access
Date of Visit: /1� Arrival Time: Fi=3G> Departure Time: � t7C7 County: Region:
Farm Name: (?nr�� � ryrtw Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: t ,&,r"�S Title:
Onsite Representative:_ —
Certified Operator: ✓�''"-��
Back-up Operator:
Location of Farm:
Swine
❑ Wean to Finish
❑ Wean to Feeder
Feeder to Finish
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Grits
❑ Boars
Latitude: 0
Phone No:
Integrator:
Operator Certification Number:
Back-up Certification Number:
Design Current Design Current
Capacity population Wet Poultry Capacity Population
❑ Layer
❑Non -Layer
Other
❑ Other �_ _ __. __�
Dry Poultry
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turke s
❑ Turkey Points
❑ Other
Discharges &Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: El Structure [I Application Field [I Other
a. Was the conveyance man-made?
Longitude: =o='
Design Current
Cattle Capacity Population
❑ Dairy Cow
aD
❑ Dai Calf
❑ iry Heifer
❑ Dry Cow
❑ Non -Dairy
❑ Beef Stocker
❑ Beet Feeder
❑ Beef Brood Cow
Number of Structures:
b. Did the discharge reach waters of the State? (Ryes, 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 Callo ❑ NA ❑ NE
❑ Yes
❑ No
[DNA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
ANo
❑ NA
❑ NE
❑ Yes
[9,No
❑ NA
❑ NE
I2/28/04 Continued

Facility Number: — Date of Inspection �b
Waste Collection & 'Treatment
�
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
(Yes A No ❑ NA ❑ NE
a. if yes, is waste level into the structural freeboard?
❑ Yes ONo ❑ NA ❑ NE
Structure I Stnrcturc 2 Structure :3 Structure .4
Structure i Structure 6
Identifier:
Spillway?:
Designed Freeboard (in): 1
Observed Freeboard (in): f�T
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 Alo ❑ 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 ZtNo ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes MNo ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes 95-No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 Ibs ❑ 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 A 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 i ❑ Yes 9 No ❑ NA ❑ NE
17. Does the facility lack adequate acreage for land application? ❑ Yes [KNo ❑ NA ❑ NE
18. Is there a lack of properly operating waste application equipment? ❑ Yes [&No ❑ NA ❑ NE
IComments (refer to question #): Explain any YES answers and/or any recommendations or any other comments. I
Use drawings of facility to better explain situations. (use additional pages as necessary):
"/r �j'!/aJ` lJ�c�Y�-r��� l�aG'f�✓lrr!�30 ���V �' it'GiV..�
Reviewer/Inspector Name 11101 Phone-
Reviewer/Inspector Signature: Date:�a-O�a
U115/U4 c.onanuea

Facility Number: Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? .Yes WNo ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes [2 No ❑ NA ❑ NE
the appropriate box. ❑ WDp ❑ Checklists ❑ Design ❑ Maps ❑ Other
21. Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
[5No
❑ 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
kNo
❑ 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
allo
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
R 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 permit or CAWMP? ❑ Yes EX -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
JgNo
❑ 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
Z,No
❑ NA
❑ NE
General Permit? (ic/ 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
RNo
❑ NA
❑ NE
12128104

} Division of Water Quality �Cl%
:Facility NumUer �(� O Division of Soil and Water Conservation
0.Other Agency
Type of Visit G�ompiiance Inspection O Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit outlne O Complaint O Follow up O Referral O Emergency O Other ❑ Denied Access
Date of Visit: Arrival Time: ; p p Departure Time: County: G41Region:
Farm Name: �� 1 e5�i tQ✓� s _ Owner Email:
Owner Name: C� Q ✓ I�5 i i r` r Phone:
Mailing Address:
Physical Address:
Facility Contact: r r %Y ,r Title: Phone No:
Onsite Representative: Sam Integrator:
Certified Operator: S'� Operator Certification Number:
Back-up Operator:
Location of Farm:
Swine
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Other
❑ Other
Back-up Certification Number:
Latitude: 0 0 = 0 = Longitude: 0 ° 0 ` =
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer
❑ Non-Layet
Dry Poultry
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ Turke I'oults
❑ Other
Discharges & 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?
Design Current
Cattle Capacity Population
❑
1) iry Cow
❑
Dairy Calf
❑
Dairy Heifer
❑
Dry Cow
❑
Non-Daity
❑
Beef Stocker
❑
Beef Feeder
❑
Beef Brood Cowl
Number of Structures; 17]
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 ZNo [I NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
M.No
❑ NA
❑ NE
❑ Yes
RNo
❑ NA
❑ NE
12128104 Continued

I
Facility Number: [}r — /1,9 Date of Inspection 11-1-16
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):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
,LNo
❑ NA
❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
❑ Yes
RNo
❑ 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
Z No
❑ NA
❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit?
❑ Yes
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
ONo
❑ 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 Drifl ❑ Application Outside of Area
12. Crop type(s)
13. Soil type(s) 'D1'!6'LY' I tom=-✓` f 1-�n =_e
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes CZNo ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? 0-Yes
❑ No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?❑ Yes
5eNo
❑ 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
RNo
❑ 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):
Ir. /'ri7t4,if j 2rj 4 6 .5 4L5 (,l1�ai� er� r�rtl j c
Reviewer/Inspector Name Phone:
Reviewer/Inspector Signature: Date:
1L/L8/U4 [.UnU f"E"

Facility Number: — Date of Inspection �a9
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes 9 No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes ELNo ❑ NA ❑ NE
the appropirate box. ❑ WUP ❑ Checklists ❑ Design El Maps ❑Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes ZNo ❑ 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?
❑ Yes
® No
❑ NA
❑ NE
❑ Yes
® No
❑ NA
❑ NE
❑ Yes
® No
❑ NA
❑ NE
❑ Yes
91 No
❑ NA
❑ NE
❑ Yes
® No
❑ NA
❑ NE
❑ Yes
ES No
❑ NA
❑ NE
❑ Yes
[51No
❑ NA
❑ NE
❑ Yes
allo
❑ NA
❑ NE
❑ Yes
® No
❑ NA
❑ NE
❑ Yes
-'E5No
❑ NA
❑ NE
❑ Yes
® No
❑ NA
❑ NE
❑ Yes [KNo ❑ NA ❑ NE
Page 3 of 3 12128104

r
N
ivision of Water Quality
Facility Number g O Division of Soil and Water Conservation��
- O Other Agency
Type of Visit Compliance Inspection O Operation Review O Structure Evaluation 0 Technical Assistance
Reason for Visit outine O Complaint O Follow up O Referral Q Emergency O Other ❑ Denied Access
Date of Visit: Arrival Time: (7 Departure Time: t) .' JD I County: --"� Region: J
Farm Name: �� f*��5�iGiFn!t�S Owner Email:
Owner Name: �!?4�P�S' Vi C - Phone:
Mailing Address:
Physical Address:
Facility Contact: e,t i Title:
Onsite Representative:
Certified Operator:
Back-up Operator:
Phone No:
Integrator: r
Operator Certification Number;
Back-up Certification Number:
Location of Farm: Latitude: [= o = i = I{ Longitude: = o 0 , = 4i
Swine
Design Current Design Current
Capacity Population : Wet Poultry Capacity Population
sh i ❑ Layer
der ❑ Non -La et
❑ Wean to Fini
ElWean to Fee
(2Feeder to Finish
kDo
LODD
❑ Farrow to Wean
❑ Farrow to Feeder
ElFarrow to Finish
ElGilts
❑ Boars
`Other
❑ Other
Dry Poultry
❑ La ers
ElNon-Layers
❑ Pullets
❑ Turkeys
El Turkey Poults
❑ Other
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ElStructure [IApplication Field [IOther
a. Was the conveyance man-made?
Design Current
Cattle Capacity Population:.
El
Dairy Cow
El
Dairy Calf
El
Daia Heifer
❑
Dry Cow
El
Non-Dairy
ElBeef
Stocker
ElBeef
Feeder
ElBeef
Brood Cow
Number of Structures: T]
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 2 No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
J3 No
❑ NA
❑ NE
❑ Yes
allo
❑ NA
❑ NE
12128104 Continued

Facility Number: — Date of Inspection
4 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 1 Structure 2 Structure 3 Structure 4
❑ Yes ® No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in): /
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes
0 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
Z 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 [I NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes
13 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 Ibs ❑ 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) f r
14,
Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
�o
❑ NA
❑ NE
15.
Does the receiving crop and/or land application site need improvement?
❑ Yes
5Z No
❑ NA
❑ NE
16.
Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?[] Yes
00 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
C-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):
11
Reviewer/Inspector Name tAe Phone: d"f
Reviewer/inspector Signature: Date:
,or 12128104 Continued

i
Facility Number: Date of Inspection
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 B No ❑ NA ❑ NE
the appropirate box. ❑ WUP ❑ Checklists ❑ Design El Maps El Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes JZ 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
I No
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
[Z No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
50 No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
10 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
® 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
19 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
[KNo
❑ 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
RNo
❑ NA
❑ NE
Comments and/or Drawings:
12128104

Type of Visit 4�1<ompliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit outlne 0 Complaint Q Follow up 0 Referral 0 Emergency O Other ❑ Denied Access
Date of Visit: Arrival Time: + 17(% I Departure Time: 110..30 1 County: j,? Farm Name: Name: ' 1 e fqr Owner Email:
Owner Name: �/►2/` ��5y ; 1 l Z-,fs 2i e- Phone:
Mailing Address:
Physical Address: r n
Facility Contact: A!5PSeiC Title:
Onsite Representative: Sew
Certified Operator:
Back-up Operator:
Region: L.Ls!
Phone No:
Integrator: tiv4
Jill
Operator Certification Number:
Back-up Certification Number:
Location of Farm: Latitude: ❑ o = t =15 Longitude: ❑ ° ❑ & ❑ 1I
Design Current
DesignMCurrent
Design Current
Swine C►apacity Population
!et, C►apacitopulation
C►attle Capacity Population
❑ Wean to Finish
❑ Layer
ja Cow
❑ Wean to Feeder
❑ Non -Layer
❑Dai Calf
Feeder to Finish Q
❑ Dairy Heifer
❑ Farrow to Wean
Dry Poultry
❑ Dry Cow
❑ Farrow to Feeder
ElNon-Dairy
❑ Farrow to Finish
El Layers
❑ Beef Stocker
❑ Gilts
❑ Non -Layers
❑Beef Feeder
❑ Boars
❑ Pullets
❑ Beef Brood Cow
❑ Turkeys
Qther
❑ Other
❑ Turkey Poults
ther
Number of Structures:
Discharees & 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
P�No
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
k No
❑ NA
❑ NE
other than from a discharge?
Page I of 3
12128104
Continued

Facility Number: -- b' Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes CgNo ❑ 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):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes [SNo ❑ NA ❑ NE
(ic/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes 10 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 EffNo ❑ 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 12 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 C&No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN> 10% or 10 ibs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
EffNo
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
[9 Yes
❑ No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
❑ Yes
0 No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
KNo
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
21No
❑ 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):
Mr, Go lle_- , c ki r 1 � j�/, vrS�Co� �xrmr�d'� Jn)S �ri n� i 1•� �i5
Reviewer/Inspector Name I Phone: J_91i?--41.3,3_=."S3LV
ReviewerfInspector Signature: Date:
Page 2 of 3 12128104 Continued

Facility Number: -- Date of Inspection ` D
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 21 No ❑ NA ❑ NE
the appropirate box. ❑ WDP ❑ Checklists ❑ Design El Maps ❑Other
21. Does record keeping need improvement? If yes, check the appropriate box below. MYes ❑ No ❑ NA ❑ NE
N 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
JeN No
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
Ja No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
jQNo
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
CKNo
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
r"No
El 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
2"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
D� 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
ERNo
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
9No
(:1 NA
❑ NE
I G1_5"Ctr ��u� G a�/�7: - � g /vim`% 6-)'/14 d,r �ui--
W�5
12128104

I
Type of Visit e'Grompliance 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 ❑ Denied Access
Date of Visit: /]`^' Arrival Time: Departure Time: County: CgD'L- Region:
Farm Name:-l.�.i_�� r•Sg C. Owner Email:
Owner Name.. e-n A de_— aS _�7'f % �Si�% Phone: r
Mailing Address: t w ezf Z �.� 1 h
Physical Address:
Facility Contact: C Title:
Onsite Representative:
Certified Operator:
Back-up Operator:
Phone No:
Integrator: IW Vez _
Operator Certification Number:
Back-up Certification Number:
Location of Farm: Latitude: ❑ o = 6 0 Longitude: ❑ ° = ` ❑
Design Current
Swine Capacity Population
Design C►urrent
5yr7nacity Population
Design Current
Cattle Capacity Population
❑ Wean to Finish
JEJ Layer
❑Dai Cow
❑ Wean to Feeder
ILI Non -Layer
❑ Dair Calf
Feeder to Finish 00
El Dairy Heifer
❑ Farrow to Wean
Dry Poultry
❑ Dry Cow
❑ Farrow to Feeder
ElNon-Dairy
❑ Farrow to Finish
❑ La ers
❑ Beef Stocker
❑ Gilts
❑Non -La Non -Layers
❑ Beef Feeder
❑ Boars
El Pullets
❑ Beef Brood Cowl
❑ Turke s
it e
❑ Other
10 Turkey Poults
JE1 Other I
Number of Structures:
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
n 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
CkNo
❑ NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
P No
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
5& No
❑ NA
❑ NE
other than from a discharge?
Page 1 of 3
12128104
Continued

Facility Number: — 6 Date of Inspection
�f
a 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 JZ No ❑ NA ❑ NE
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes 0 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 R 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 JKNo ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes XNo ❑ 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. Soiltype(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
SNo
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
M Yes
No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
❑ Yes
4 No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
ANo
❑ NA
❑ NE
18, Is there a lack of properly operating waste application equipment?
❑ Yes
Flo
❑ 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 %� �.,� — f Phone. O--IY33d�
Reviewer/Inspector Signature: Date:
Page 2 of 3 12128104 Continued

jFacility Number: — Date of Inspection1`
r� Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes [R No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes allo ❑ NA ❑ NE
the appropriate box. ❑ WCP ❑ Checklists ❑ Design ❑Maps ❑Other
21. Does record keeping need improvement? if yes, check the appropriate box below. ayes ❑ 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 CRWeather Code
22. Did the facility fail to install and maintain a rain gauge?
❑ Yes
R No
❑ NA
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
ruraj No
❑ NA
❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
[4 No
❑ NA
❑ NE
25. Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
14 No
❑ NA
❑ NE
26. Did the facility fail to have an actively certified operator in charge?
❑ Yes
WNo
❑ NA
❑ NE
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
❑ No
[9NA
❑ NE
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
[Q No
❑ NA
❑ NE
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
KNo
❑ 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
5ZNo
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
3 I. Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
ZNo
❑ 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
ANo
❑ NA
❑ NE
33. Does facility require a follow-up visit by same agency?
❑ Yes
KNo
❑ NA
❑ NE
al Comments and/or
10kee We-a4o, and e �
Page 3 of 3 12128104

Type of Visit &-Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit 0 Routine 0 Complaint 0 Fallow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: �Arrival Time: ! O Departure Time: a'O County: RIA2 ��e� Region: Y
Farm Name: i �im_5�7 Y ��r y-m.� Owner Email:
Owner Name: f - kci_r-/y-.4��- ,j j—P__S_n—%__�- --- Phone: 91 L
Mailing Address: De—aj
Physical Address:
Facility Contact: Spy Title: Phone No:.
Onsite Representative: Integrator: rn u �r,
Certified Operator:. __ ��_ ______ __ _ Operator Certification Number: 52_
Back-up Operator: Back-up Certification Number:
Location of Farm: Latitude: = e = 4 = Longitude: = ° = d
Swine
Wean to Finish
Wean to Feeder
feeder to Finish
Farrow to Wean
Farrow to Feeder
Gilts
Boars
Other
❑ Other
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer
❑ Non -La et
Dry Poultry
Non-L
Pullets
LJ Turkey Poults
❑ Other
Discharees & 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)
Design Current
Cattle Capacity Population
❑ Dairy Cow
❑ Dairy Calf
❑ Dairy Heifer
❑ Dry Cow
❑ Non -Dairy
❑ Beef Stocker
❑ Beef Feeder
❑ Beef Brood Cow
c. What is the estimated volume that reached waters of the State (gallons)?
Number of Structures: Y1
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 [ENo ❑ NA ❑ NE
❑ Yes
EgNo
❑ NA
❑ NE
❑ Yes
M No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
(& No
❑ Yes q No ❑ NA ❑ NE
❑ Yes [3dNo ❑ NA ❑ NE
12128104 Continued

•
Faciilfy Number:,2!Z Z&17
Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
XNo ❑ NA
El 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:
Spillway?:
Designed Freeboard (in):
0
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
R 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?
19 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
5dNo ❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
;4 No ❑ NA
❑ NE
maintenance/improvement?
It. Is there evidence of incorrect application? If yes, check the appropriate box below.
❑ Yes
ro 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) /+�.MJylUrlr. %e�i, 51�9,yQ�i'.�✓...
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
r'o No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
ayes
❑ No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination%❑
Yes
RNo
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
Q No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
M No
❑ NA
❑ NE
, W_ y+C-,c I'1'lan- Wi I l i M67--v 11 Nr'cU IHajr&eGuar , en i.5 J641
Reviewer/Inspector Name ,i ,� �� t .. Phone:
Reviewer/Inspector Signature: Date: Q — p
12128104 Continued

Faaftty Number: Date of Inspection
Required Records & Documents
19. Did the facility fail to have 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 91Yes ❑ No ❑ NA ❑ NE
the appropirate box.
❑ WUP. El Checklists El Design 14 Maps El Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes R 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? (iel 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
® No
❑ NA
❑ NE
❑ Yes
[XNo
❑ NA
❑ NE
❑ Yes
5� No
❑ NA
❑ NE
Yes
[No
❑ NA
❑ NE
❑ Yes
54 No
❑ NA
❑ NE
,WYes
❑ No
r NA
❑ NE
❑ Yes allo ❑ NA ❑ NE
❑ Yes ®,No ❑ NA ❑ NE
❑ Yes KNo ❑ NA ❑ NE
❑ Yes 54No ❑ NA ❑ NE
❑ Yes
� No
El NA
El NE
❑ Yes
^ No
❑ NA
❑ NE
"itional Comments and/or Drawings:
o? y o k
12128104

(Type of Visit • Compliance Inspection O Operation Review O Lagoon Evaluation I
Reason for Visit • Routine O Complaint O Follow up O Emergency [notification O Other ❑ Denied Access
Facility Number Date of Visit: / 1t . Tune: ��
O Not Operational Q Below Threshold
Ml' eerndtted 13 Certified 13 Conditionally Certified 13 Registered Date Last Operated or Above Threshold:
FarmNameCounty. _ �.tea_._.___.............»»....» GRb...»»..
Owner Name: �ar ��..».»..»....»:.»......»....................... ' Phone No: ». ��. .�! �.t� �..�i!!........... .._..... »_.
Mailing Address:....8� y ... �.�u�. ._.%rT.ot r!t.»...!QQ1 .................. EL �z g33 `...
Facility Contact: ... »..._...... 66r..la ... ........ Title:.._ ..............»...._.»......»..».»........_... Phone No:......_...»...._................»
Onsite Representative: ...... C/1ryrle&............ Gj.�I ice.... ..... _................................ ' Integrator:
Certified Operator:._......._.». �t�irf.Cs............ _... : %�ct,,�t� ....................... Operator Certification Member:......,�.G>i o... »» ._..
Location of Farm:
M16wine ❑ Poultry ❑ Cattle 0 Horse Latitude • 4 " Longitude L�J1 �119
Discharges & Stream Impacts
I. Is any discharge observed from any part of the operation? ❑ Yes G--N6
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man -[Wade? ❑ Yes D.K6
b. If discharge is observed, did it reach Water of the State? (If yes, notify DWQ) ❑ Yes ❑-Ko-
c. If discharge is observed, what is the estimated flow in gal/min? _�--
d. Does discharge bypass a lagoon system? (If yes, notify DWQ) ❑ Yes [Wo
2. Is there evidence of past discharge from any part of the operation? ❑ Yes [Wo
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes GNo
Waste Collection & Treatment
4. Is storage capacity (freeboard plies storm storage) less than adequate? ❑ Spillway ❑ Yes ENO
Structure I Structure 2 Structure 3 Structure 4 Structure S Structure 6
Identifier: ......».»»........ --- ».».».» ».... ,.»»».....
Frecboard (inches): 3 0 r,
12112103 Continued

Facility Number: -- J Date of Inspection -o
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, ❑ Yes [j-No
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or ❑ Yes ErfFo
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/improvement? ❑ Yes [314o
8. Does any part of the waste management system other than waste structures require maintenance/improvement? ❑ Yes DKO
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level ❑ Yes Ova
elevation markings?
Waste Annlication
10. Are there any buffers that need maintenance/improvement? ❑ Yes ONO
11. Is there evidence of over application? If yes, check the appropriate box below. ❑ Yes
❑ Excessive Pounding ❑ PAN ❑ Hydraulic Overload [I Frozen Ground [I Copper and/or Zinc
,Y•s7r sv
12. Crop type fe.x,..ale
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CA 'I. '. . II W1VIP)? ❑Yes [}lam
14. a) Does the facility lack adequate acreage for land application? ❑ Yes ❑ No
b) Does the facility need a wettable acre determination? ❑ Yes ❑ No
c) This facility is pended for a wettable acre determination? ❑ Yes ❑ No
15. Does the receiving crop need improvement? ❑ Yes [44ro
16. Is there a lack of adequate waste application equipment? ❑ Yes<o
Odor L%sues
17. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge attar below ❑ Yes ❑ No
liquid level of lagoon or storage pond with no agitation?
18. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes M-No
19. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt, ❑ Yes eggo
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 ❑ yes [RK0
Air Quality representative immediately.
.e * � i3r-��;'�ur��v'•,naseq.., wrar�a�,xmax:,'isam�i�itu"_�srw�a�?^a:ns�z,z�n•ni: r:.s:�n..C'.'td, ito u•sr��zms;�xi�x��i � �,e�, ..rri sir, 's '.`r,
�Comm�nts (�r��ei�'erqg�to,�gaes6on��i) Explain �nyYi�.S�answtrs`antilorsu�y t•ecommendat#oas,orgaydat�ercansmeats. �. �_ R�, n,�:
-
Usle
drgwmgso! facrhty W betttr' Igiin�sitetations.{nsesdditianal.pagcs°aseaccessary)�j told COPY ❑Final Notes �.
A
P/a'r l'f'/ie� w; Fti /P• � /C /jT o r�r �'a o n A aw f-V
l�as 1'9�anS 7"0 /'t,SP�.'' '� Co.,s7�r ��'C�d� ►�Y1 Sj�^�� v� �Cvr9��
gi
t "«�iT;i ��'t E�' � �' `�� "n 3 "' 1
Reviewer/Inspector Name`/�ia'r.,' .�' i ,� : , € , _ �� . e:n. , ��=
Reviewer/Inspector Signature: Date:
1-7/12/03 Continued

F;9ty Number: GT ..`� Date of Inspection
Reouired Records & Documents
21. Fail to have Certificate of Coverage & General Permit or other Permit readily available? 9-fes ❑ No
22. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
Oe! , c ec s, dysigtriaaps; etc.) ❑Yes S
23. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes ❑ No
OAVOte-ApphGadoa< ❑-fre4=d--O Waste-1 r&lysis esgal g
'7-10 —> 1, �' S- 3 -3 3.2
24. Is facility not in compliance with any applicable setback criteria in effect at the time of design? ❑ Yes S-No
25. Did the facility fail to have a actively certified operator in charge? [:]Yes gil-0
26. Fail to notify regional DWQ of emergency situations as required by General Permit?
(ie/ discharge, freeboard problems, over application) ❑ Yes (Wo
27. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative? ❑ Yes OW56
28. Does facility require a follow-up visit by same agency? ❑ Yes Q-W
29. Were any additional problems noted which cause noncompliance of the Certified AWMP? ❑ Yes ❑-No
NPDES Permitted Facilities
30. Is the facility covered under a NPDES Permit? (If no, skip questions 31-35) ❑ Yes MV%J�
31. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes ❑ No
32. Did the facility fail to install and maintain a rain gauge? ❑ Yes ❑ 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
12112103

O Routine O Complaint O Follow-up of DWQ inspection O Follow-up of DSWC review O Other
Date of Inspection
Facility Number 6 Time of Inspection 3; or] 24 hr. (hh:mm)
Total Time (in fraction of hours
Farm Status: ❑ Registered ❑ Applied for Permit (ex:1.25 for 1 hr 15 min)) Spent on Review 0
Cl Certified ❑ Permitted or Inspection includes travel andprocessing)
❑ Not Operational Date Last Operated : ...... ............................ »...... ................ ............................ ./........
f................ »...................................
Farm Name: 4Zl..�i� le��......1.....!1 �.� ....................... County:............. ,L,t !./ !`.............//...�.......................
Land Owner Name:....... -ZA..1 .... , �[, !.�� .............»............... Phone No:...OZe)
............ T.��...........
Facility Conctact:
Mailing Address:
Onsite Representative: ...a -/I .. ..1 /,1.F............................
Certified Operator:..... q'el�s ............S,e�/�
Location of Farm:
Integrator:...,�..lP!''f.,<r..✓..N..�.C? s�.Ltly��,l/. �!�
Operator Certification Number: .I.Z.
Latitude Longitude �• 0` �'
Type of Operation and Design Capacity
Swi a 3�.DpsignCurren Design Current ff� w DesignCurrent
{.. Ca aciPo ulation'.Poultry ,.Ca' acl bPa` ulation , Caitle �Ca aci >Po `ul tion
❑ Wean to Feeder ❑ I er ❑ Dairy
Feeder to Finishvro ]E] Non -Layer ❑ Non-Dairy
Farrow to Wean
11 Farrow to Feeder otal :Design Gapaetty .
Farrow to Finish
Other
"�,^'.w^,-�cr�rS"."....."•,y"r�,...x ;.:._...h.-.�.�;:�. . ,..,.u�._ s.. ". ...�:x�. z:6F. �`a?,,�:Y�.xs�
lm
Number ofiLagoons / HoldiiigxPonds ❑Subsurface Drains Present
jJ § ' ❑ Lagoon Area ❑Spray Fieid Area
- + Y4�
Ggneraj
1. Are there any buffers that need maintenance/improvement?
2. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Lagoon ❑ Spray field ❑ Other
a. If discharge is observed, was the conveyance man-made?
b. If discharge is observed, did it reach Surface Water'? (If yes, notify DWQ)
c. If discharge is observed, what is the estimated flow in gal/min?
d. Does discharge bypass a lagoon system? (if yes, notify DWQ)
3. Is there evidence of past discharge from any part of the operation?
4. Were there any adverse impacts to the waters of the State other than from a discharge?
. Does any part of the waste management system (other than lagoons/holding ponds) require
4/30/97 maintenance/improvement?
❑ Yes )(No
❑ Yes �(No
❑ Yes �No
❑ Yes XNo
❑ Yes
No
❑ Yes
No
❑ Yes
No
❑ Yes
o
Continued on back

Facility Number: ......--a.2-
6. Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes KNo
7. Did the facility fail to have a certified operator in responsible charge?
❑ Yes XNo
8. Are there lagoons or storage ponds on site which need to be properly closed?
❑ Yes )(No
S(jagoonj and/or Holding Pon"
9. Is storage capacity (freeboard plus storm storage) less than adequate?
❑ Yes XNo
2 Structure 3 Structure 4 Structure
Freeboard (ft): Structure I 2f Cz
Structure 6
.Structure
Y" .5
.
10. Is seepage observed from any of the structures?
❑ Yes XNo
11. Is erosion, or any other threats to the integrity of any of the structures observed?
❑ Yes No
12. Do any of the structures need maintenance/improvement?
❑ YesANo
(If any of questions 9-12 was answered yes, and the situation poses an
Immediate public health or environmental threat, notify DWQ)
13. Do any of the structures lack adequate minimum or maximum liquid level markers?
❑ Yes kNo
WasteApplicatlon
14. Is there. physical evidence of over application?
❑ Yes KNo
(If in excess of WIMP, or runofffentering waters of the State, notify DWQ)
15. Crop type:FrC�n�,fl'...............................................................................................................................................
16. Do the receiving crops differ with those designated in the Animal Waste Management Plan (AWMP)?
❑ Yes No
17. Does the facility have a lack of adequate acreage for land application?
❑ Yes No
18. Does the receiving crop need improvement?
❑ Yes XNo
19. Is there a lack of available waste application equipment?
❑ Yes o
20. Does facility require a follow-up visit by same agency?.
❑ Yes No
21. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes &rNo
For Certified-Eacilities QUIP
22. Does the facility fail to have a copy of the Animal Waste Management Plan readily available?
❑ Yes XNo
23. Were any additional problems noted which cause noncompliance of the Certified AWMP?
Yes ❑ No
24. Does record keeping need improvement? Yes ❑ No
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 addittonal pages as necessary)
_ 4
Reviewer/Inspector Name ".77
Reviewer/Inspector Signature: Date: --%" 92
-r-
cc. Division of Water Quality, Water Quality Section, Facility Assessment Unit 4/30/97

f
vision of Water Resources
Fucilily Number - O Division of Soil antl Water Conservation
N Other Agency
Type of Visit: ompliance Inspection 0 Operation Review 0 Structure Evaluation Q Technical Assistance
Reason for Visit: t2M_olutine 0 Complaint O Follow-up O Referral O Emergency 0 Other Q Denied Access
Date of Visit: 4L�--lam Arrival Time: Departure Time: ®a County: Z/Region:
Farm Name: �i%f�,- ri'rst s Owner Email:
Owner Name: 46Len Phone:
Mailing Address:
Physical Address:
Facility Contact:
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Title: Phone:
Integrator: ,�5�ixr /D�•
Certification Number: 24 2
Certification Number:
Latitude: Longitude:
Design Current
Design
Current
��lll
llesign
H� 1�11ii
Current
Swine Capacity Pop.
Wet Poultry
Capacity
Pop.
Cattle
Cap iry
Pop.
Finish
La er
DairyCow
eeder
Nan -La er
DairyCalf
Finish
DairyHeifer
[ptl
Wean
Design
Current
D Caw
Feeder
D , l?oultr. ,
Ca aci
P,o
Non -Dairy
Finish
a ersBeef
Stocker
Non -La ers
Beef Feeder
Pullets
Beef Brood Cow
Turke s
{7thc
-key Poults
Other
Other
Discharaes and Stream Impacts
I. 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 [allo ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑Yes
❑No
❑NA
❑NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
JQNo
❑ NA
❑ NE
❑ Yes
ZC No
❑ NA
❑ NE
Page 1 of 3
21412015 Continued

Facility Number: - / f� Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? 0 Yes ® 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):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes J�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
0 Yes No ❑ NA
❑ NE
waste management or closure plan?
If any or 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 0,No ❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes Q 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 ["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): 'Alx� 0V
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 [Z No ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes P�].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? D Yes CE No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check [:]Yes [&No ❑ NA ❑ NE
the appropriate box.
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes jEgNo ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis 0 Waste Transfers ❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rainfall Inspections ❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes 2�No ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes L!�No ❑ NA ❑ NE
Page 2 of 3 21412015 Continued

Facili Number: jDate of Inspection:
1 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 IS 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 provide documentation of an actively certified operator in charge? ❑ Yes 2_No
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes [SNo
Other Issues
❑ NA ❑ NE
❑NA ❑NE
❑ NA ❑ NE
❑ NA ❑ NE
28. Did the.facility fail to properly dispose of dead animals with 24 hours and/or document
[:j Yes
[&No
❑ NA
❑ NE
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
2_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
[�3,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
QNo
❑ NA
❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
E[No
[] NA
❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
[allo
❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
[] Yes'
Ea No
❑ NA
❑ NE
Comments'(refer to question';#} Explain uny'.YES answers 6d/gr an1. y additional xecnmmendations o1.r a other eomments`'
Use drawln s,offacilityit0 better explain situations'(use addltlonal; ages a 1 neeC9s8 ) '' �..l�� , „<_r1,13,., '_,; ...,.���,4''.i'u�l Ills` �aJ�i ill t $ 'r���hdjillill; `s�a1P,�
Reviewer/Inspector Name: Phone:
Reviewerllnspector Signature: Date:
Page 3 of 3
21412015