260019_INSPECTIONS_20171231

i
(Type of Visit: Q)'70utine
ance Inspection U Operation Review U Structure Evaluation U Technical Assistance
Reason for Visit: O Complaint O Follow-up O Referral O Emergency Q Other Q Denied Access I
Date of Visit: K Arrival Time: �," p Departure Time: 4 3 County:C'u�cc ,
Farm Name: i6p,nt„_k (<t4ubr-4AIt it Owner Email:
cY -
Owner Name: a2Vt V a Phone:
Mailing Address:
Physical Address:
Facility Contact: c( " Title:
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Phone: Integrator: 14 410
Region: r 1 ?i
Certification Number: 16 ! 12
Certification Number:
Longitude:
Design Current
Design
Current
Design Current
Swine
Capacity Pop.
Wet Poultry
Capacity
Pop.
Cattle Capacity Pop.
Wean to Finish
Layer
Non -La er
I
Dairy Cow
Wean to Feeder
Dairy Calf
Daig Heifer
Dry Cow
Feeder to Finish
d Q
b
Design Current
Farrow to Wean
Farrow to Feeder
Dr,Y P,oultr,
Ca aci
P,o ,
Non -Dairy
Farrow to Finish
Beef Stocker
Layers
Non -Layers
Gilts
Beef Feeder
Boars
Pullets
Beef Brood Cow
211
Turkeys
().thee ifl,
Turke Poults
Other
Other
Discharges and Stream impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
❑ Yes 0_N6—_❑ NA ❑ NE
❑ Yes ❑ No NA ❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWR)
❑ Yes
D No
[-N-�r ❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (if yes, notify DWR)
❑ Yes
❑ No
D< ❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
[]"No
❑ NA ❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters
❑ Yes
[�PNo
❑ NA ❑ NE
of the State other than from a discharge?
Page 1 of 3
4
21412015 Continued

Facilio Number: - Date of Ins ection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfali) less than adequate? ❑ Yes D-NV— ❑ NSA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No Q`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
[CIS
❑ 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
[-5oo
❑ 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
© 'Nolt
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
Q-i'd'o
❑ 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
[D_N'cr'
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
Q'1 o
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes []•N6' ❑ 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 ofWind Drift ❑ Application Outside of Approved Area
ro
12. Crop Type(s): -- -- ( (,j fs i�e'-at'e(%of s-i' 0— Aul
e
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
15. Does the receiving crop and/or land application site need improvement?
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
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
[Ej<
❑ NA
❑ NE
❑ Yes
IJ"I`10
❑ NA
❑ NE
❑ Yes
LJ o
❑ NA
❑ NE
❑ Yes L No ❑ NA ❑ NE
❑ YesErKlo"'
❑ NA ❑ NE
❑ Yes No
[:)Yes fo
[DNA ❑ NE
❑ NA ❑ NE
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box bet Yes No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis [Soil Analysis ❑ Waste Transfers ❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and i" Rainfall Inspections ❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes dNo ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes ZNo ❑ NA ❑ NE
Page 2 of 3 21412015 Continued

Facili Number: Date of Inspection: 11
24. Did the facility fail to calibrate waste application equipment as required by the permit? [] Yes "Flo ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes Q'1 o ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26, Did the facility fail provide documentation of an actively certified operator in charge? ❑ Yes ONo ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? Yes E<o ❑ NA ❑ NE
Other Issues
28, Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
34. Does the facility require a follow-up visit by the same agency?
❑ Yes No ❑ NA ❑ NE
❑ Yes 10 ❑ NA ❑ NE
❑ Yes ED J o ❑ NA ❑ NE
❑ Yes Ef<o ❑ NA ❑ NE
[:]Yes [i]No
[:]Yes E No
❑ Yes dNo
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Reviewer/Inspector Signature: r Date:
Page 3 of 3 21412015

vision of Water Resources
Facility Number ®- O Division of Soil and Water Conservation
,-h Q Other Agency
Type of Visit: CIrTompliance Inspection 0 Operation Review O Structure Evaluation Q Technical Assistance
Reason for Visit: Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Bch I Arrival Time: Departure Time ly/ f County: a4 ts-64 Region:
Farm Name: XeJ1w Favwcdyvk Owner Email:
Owner Name: 4 eL^ Phone:
Mailing Address:
Physical Address:
Facility Contact: Title:
Onsite Representative:
Certified Operator: L
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
Boars
Other
Other
Latitude:
Phone:
Integrator:✓lrG
Certification Number:
T
Certification Number:
Design Current Design Current
Capacity Pop. Wet Poultry Capacity Pop.
La er
Non -La er
ury rounry
Layers
Non -Layers
Pullets
Turkeys
Turkey Puults
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 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?
Longitude:
Design Current
Cattle Capacity Pop.
Dairy Cow
Dairy Calf
Dairy Heifer
Dry Cow
.Non -Dairy
Beef Stocker
Beef Feeder
Beef Brood Cow
❑ Yes E+ o ❑ NA ❑ NE
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes EfNo
❑ Yes ❑.No
O NA ❑ NE
Q NA ❑ NE
[�NA
❑ NE
❑ NA
❑ NE
❑ NA
❑ NE
Page 1 of 3 21412015 Continued

Fs�cilit umber: - Date of In ection:
Waste Collection & Treatment
4. I;' storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes [..}-4e­o NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No �A ❑ 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 ©011n ❑ NA ❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a ❑ Yes [E' No ❑ NA ❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWR
7. Do any of the structures need maintenance or improvement?
❑ Yes E]"No
❑ NA
❑ NE
8, Do any of the structures lack adequate markers as required by the permit?
❑ Yes Ej."No
[] NA
❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures
require ❑ Yes [ 0!�o
❑ NA
❑ NE
maintenance or improvement?
Waste Apglication
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes [31 o
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes E No
❑ NA
❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground
❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into
Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift
❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
[�Qo
❑ NA
❑ NE
15, Does the receiving crop and/or land application site need improvement?
❑ Yes
[jjo�4o
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
D Yes
[;3,<o
❑ NA
[] NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
E�J<o
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
[2"No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
FXNo
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
[IITINo
[] 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 [2�1No
❑ 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 21412015 Continued

Ficili umber: - Date of Ins ection:? -,a-t 77
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes 4EI No ❑ NA ❑ NE
1.
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes B<o ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey []Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge? ❑ Yes &No ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes E]K0 ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
34. Does the facility require a follow-up visit by the same agency?
slu�s��y� is-a3-I6 o-3.s,
Reviewer/Inspector Name
Reviewer/Inspector Signature:
Page 3 of 3
❑ Yes Q No ❑ NA ❑ NE
❑ Yes E� No ❑ NA ❑ NE
❑ Yes ❑,No ❑ NA ❑ NE
❑ Yes ❑0&o ❑ NA ❑ NE
❑ Yes
[!I -No
❑ NA
❑ NE
❑ Yes
[TNo
❑ NA
❑ NE
❑ Yes
dNo
❑ NA
❑ NE
Phone:!
Date:
21412015

(Type of Visit: QJI-Cbmpliance Inspection U Operation Review U Structure Evaluation U Technical Assistance
Reason for Visit: Q<Outine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: Departure Time: b County: Cc& r ,&V Region: ! �'
Farm Name: A,*4& o4 Cayes yv G O Owner Email:
Owner Name: R -Tgyo Phone:
Mailing Address:
Physical Address:
� /j r
Facility Contact: drilu 09 V Title:
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Discharees and Stream Impacts
Latitude:
Phone:
Integrator:.i
Certification Number: 16-T11
Certification Number:
Longitude:
1. Is any discharge observed from any part of the operation?
[—]Yes
D-K°
❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
❑ Yes
❑ No
[]--N-A
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWR)
❑ Yes
❑ No
[ A
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (if yes, notify DWR)
[] Yes
❑ No
[3-NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
[TNo
❑ NA
❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters
❑ Yes
�No
❑ NA
❑ NE
of the State other than from a discharge?
Page 1 of 3 21412014 Continued

Facility Number: 1 4 jDate of Ins ection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes [gLNor ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No Q-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 Qd ❑ NA ❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a [:]Yes e No ❑ NA ❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWR
7. Do any of the structures need maintenance or improvement? ❑ Yes a <To ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes Q'< ❑ 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 Vo [] NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes 0'i�o ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes Lam' o ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or i01bs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
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
(�Pd�
❑ NA
❑ NE
❑ Yes
raj'Vo
❑ NA
❑ NE
[:]Yes
ICJ '` 0
❑ NA
❑ NE
❑ Yes Ll�l'1VO ❑ NA ❑ NE
❑ Yes NA ❑ NE
[]Yes �o ❑ NA ❑ NE
❑ Yes Z No ❑ NA ❑ NE
❑WUP ❑Checklists [:]Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes ❑'t<'o
❑ 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 eNo
�]NA ❑NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 21412014 Continued

Faclli Number: Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes [�No ❑ NA ❑ NE
25.'Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes �o ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge? [:]Yes [�No ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes ENo ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
®moo
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
[2'1lo
❑ NA 0 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
ZNo
❑ 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
ff No
❑ NA ❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
Ef No
❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
ff No
❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
ffNo
❑ NA ❑ NE
Comments (refer to question #):-Explain anyYES answers -and/or any, additional=recammendations or any other eamments
Use drawings of facility to better explain 'situations (use additional pages.as neeessary} �
..
.
C4�(Lr41o, -- cf-- 3 -I f
Reviewer/Inspector Name:
Reviewer/Inspector Signature;
Page 3 of 3
Phone:
Date: ��y
2/4/2074

(� I bus A? Av. 15 4�)
Type of Visit: UCom lance Inspection U Operation Review Q Structure Evaluation Q Technical Assistance
Reason for Visit: outine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
---
Date of Visit: Arrival Time: o= Departure Time: EZ= County:Co K6te. Regiot� 6�
Farm Name: Owner Email: r
Owner Name: a p Phone:
Mailing Address:
Physical Address:
Facility Contact:
TZMA F r Title:
Phone:
Onsite Representative: Integrator: zqV' Lb_
Certified Operator: j Certification Number: f 6 Y�
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
Design Current
Current
Design Current
Swine Capacity Pop.
Wet Poultry
Capacity
Pop.
Cattle Capacity Pop.
Wean to Finish
EDesign
La er
Dai Cow
Wean to Feeder
Non -La er
Dai Calf
Feeder to Finish
Dai Heifer
Farrow to Wean
L
Design
Current
Dry Cow
Farrow to Feeder
1]t, butt ,
Ca .acl
P,o
Non -Dairy
Farrow to Finish
Layers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turke s
Other
Turkey Poults
Other
Other
Discharges and Stream Imnacts
1. Is any discharge observed from any part of the operation?
[:]Yes
05..N� NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
❑ Yes
[] No [}#A
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWR)
❑ Yes
❑ No D-NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWR)
❑ Yes
❑ No ❑'NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
❑ NA
go,[:]
❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
❑ Yeso
NA
❑ NE
Page 1 of 3
21412014 Continued

Fueili "Number: - Date of Ins ection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes E�-�A ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No 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 [. Ko ❑ 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 Q110 ❑ 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 —/ [] NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes ��o/ ❑ 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 []- ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes Q-5'o ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes D4_0 ❑ 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):
cJet SG D
13. Soil Type(s): C' fey (,��M No '_
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
EJ11'i_❑ NA
[3 NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
[]-PQ'o
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
[ -W
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
[�'10
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
[ " oo
❑ 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
u�" o
❑ NA
❑ NE
the appropriate box.
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes 2No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Weather Code
❑ Rainfall ❑ Stocking [] Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rainfall Inspections ❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? ❑ YesrNo
❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? [:]Yes ❑ NA ❑ NE
Page 2 of 3 21412014 Continued

acility tuber: - Date of Ins ection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes Z[-N� ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes C3_Nh� 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?
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately,
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
❑ Yes ffj1To ❑ NA ❑ NE
❑ Yes Zo
[3 NA ❑ NE
[[::]Yes ❑ NA ❑ NE
❑ Yes [_ ❑ NA ❑ NE
❑ Yes ®-Ko- ❑ NA ❑ NE
31. Do su urface file drains exist at the facility? If yes, check the appropriate box below. es ❑ No ❑ NA
Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes e-Y o— ❑ NA
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes [�Ko ❑ NA
34. Does the facility require a follow-up visit by the same agency? ❑ Yes ❑i- o ❑ NA
❑ NE
❑ NE
❑ NE
❑ NE
(Comments (refer to question ##): Explain any; YES -answers and/or any additional recommendations or any 6her comments
Use drawinss of facility to better explain situations(usc:additiona!'paaesias necessary),.
ca 1; g4 IkO6
1�Reviewed]nspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
q67
2.71 P - 3� (o 6
Phone:
Date:-

" ivision of Water Quality
Facility Number - J"[ Division of Soil and Water Conservation.
a Q Other Agency
Type of Visit: Oo6oinnlince Inspection 0 Operation Review Q Structure Evaluation C) Technical Assistance
Reason for Visit: outine O Complaint O Follow-up O Referral O Emergency O Other O Denied Access
1
Date of Visit: Arrival Time: r�r� Departure Time: County: �^ Region:
Farm Name: Owner Email:
Owner Name: V� Phone:
Mailing Address:
Physical Address:
Facility Contact: Title: C9[_.J Phone:
Onsite Representative: Integrator: 1 ! V
Certified Operator: �'� Certification Number: 16 tLy
Back-up Operator:
Location of Farm:
Swine
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feedej
Farrow to Finish
Gilts
Boars
Other
Other
Certification Number:
Latitude:
Design Current Design Current
Capacity Pop. Wet Poultry Capacity Pop.
L
ayer
Nou
Poults
Design Current
Discharses and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other;
a: Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
Longitude:
Design Current
Cattle Capacity Pop.
Dairy Cow
Dairy Calf
Dairy Heifer
Dry Cow
.Non -Dairy
Beef Stocker
Beef Feeder
Beef Brood Cow
[3 Yes �NA ❑ NE
[:]Yes
❑ No
A
❑ NE
[:]Yes
[:]No
NE
d. Does the discharge bypass the waste management system? (If yes, notify DWQ) [:]Yes ❑ No NA ❑ NE
2. Is there evidence of a past discharge from any part of the operation? ❑ Yes [3'9❑ NA ❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters [:]Yes ��No ❑ NA [] NE
of the State other than from a discharge?
4
Page I of 3 214120II Continued

Facili um er: - Date of Ins ection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes [] 45-_n NA ❑ NE
a. If yes, is waste level into the structural freeboard?
Structure I 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?
(i.e., 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 B-NX--❑ NE
Structure 5 Structure 6
❑ Yes KD bk r❑ NA ❑ NE
❑ Yes D�310 ❑ 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 [2�o
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes [![i<oo
❑ 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 BIC
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes [ Na
❑ NA
❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground
[] Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure
to Incorporate Manure/Sludge into
Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift
❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s):
14. Do the receiving
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
❑ Yes
[TNo
[3 NA
No
❑ NA
1�1<0
❑ NA
❑ Yes No
❑ Yes KNNo
❑ NE
❑ NE
❑NA ❑NE
❑ NA ❑ NE
❑ Yes I1V u ❑ NA ❑ NE
[] Yes No [DNA ❑ NE
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. [] Yes No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Weather Code
❑ Rainfall []Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rainfall Inspections ❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes EJ No c ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes 6KO ❑ NA ❑ NE
Page 2 of 3 21412011 Continued A

Baoili *Number: - Date of Ins ection:
24. Did the fa c lity fail to calibrate waste application equipment as required by the permit? ❑ Yes Cg"N�o ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes C5 o ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge? ❑ Yes L!20<o ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes �Ko ❑ 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 Vo ❑ 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
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?
imments (refer to question #): Explain any YES -answers an
e drdwings.of:facility to better explain situations (use additl
�. C. 6 A,+ tin - �- ('7,
5&.
ny-additional
❑ Yes ®4lo ❑ NA ❑ NE
❑ Yes Tlo ❑ NA ❑ NE
❑ Yes �10
❑ Yes [INo
❑ Yes F2<0
S-7
�„�,v b•ys
❑ NA ❑ NE
[DNA []NE
❑ NA ❑ NE
Reviewer/Inspector Name: L Phone*
Reviewer/Inspector Signature: 9-0Date:
Page 3 of 3 2/4 Olt

R1aolaaa13
Type of Visit: 0 Compliance Inspection 0 Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit: Q'Routine 0 Complaint 0 Follow-up O Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: W Arrival Time: Departure Time: County: G
Farm Name: S,qr lj MMm w Palm �Ci���(y,�(� Owner Email:
—4 J
Owner Name: Phone:
Mailing Address:
Physical Address:
Region: Re
Facility Contact: Yj Title: ern-er Phone:
Onsite Representative: 4"Integrator: 5IR111n *Wow PICNI
Certified Operator: 4 L Certification Number: lt?V33
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
Design Current
Swine Capacity Pop.
Wean to Finish
Wet Poultry
Layer
Non —Layer
Design
Capacity
Current
Pop.
Desigu Current
Cattle Capacity Pop.
DairyCow
DairyCalf
Wean to Feeder
Feeder to Finish
DairyHeifer
Farrow to Wean
Design
C►urrent
D Caw
Farrow to Feeder
Dr. P,oultr, Ca aci Po P.
Non -Dairy
Farrow to Finish
Layers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Othc
Other
Turke s
I ITurkeyPoults
I 10ther
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?
❑Yes 2No. [DNA [3 NE
❑ Yes ❑ No ❑ NA ❑ NE
Yes [] No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
® No
❑ NA
❑ NE
❑ Yes
® No
❑ NA
❑ NE
Page 1 of 3 21412011 Continued

Wacility 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. 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
❑ 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
C2 No
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
a 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 Ai mlication
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):
1 W
kIJ
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
® No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
® No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
No
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
® No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
® No
❑ 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.
❑WUP ❑Checklists ❑Design ❑ Maps ❑ Lease Agreements
❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
51 No
❑ NA
❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis
❑ Waste Transfers
[3 Weather Code
❑ Rainfall [] Stocking ❑ Crop Yield ❑ 120 Minute Inspections []Monthly and I" Rainfall Inspections
❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge?
❑ Yes
® No
❑ NA
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
❑ No
CR NA
❑ NE
Page 2 of 3
21412011 Continued

Wacility Number, -JCJ Date of Ins ection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes C' No ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes CR 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?
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
Other issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately.
30, Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
CR No
❑ NA
❑ NE
❑ Yes
❑ No
[RNA
❑ NE
❑ Yes
®No
❑ NA
❑ NE
❑ Yes N No ❑ NA ❑ NE
❑ Yes
0No
❑ NA
❑ NE
❑ Yes
Ej�`No
❑ NA
❑ NE
❑ Yes CR No
❑ Yes ® No
[:]Yes ® No
❑NA ❑NE
❑NA ❑NE
❑ NA ❑ NE
Comments (refer to question #): Explain any YES answers and/or any additional recommendations or any other comments.'-
Use drawings of facility to better explain situations (use additional pages as necessary). ;.
�),5. LfmQ_aef4ei- Wmhb - cola.
Goed teom ei'eld�4 re(ordr,
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
.schl]-1� Phone:Q/�
Date: 59A
21412011

Facility No. :�&J�Farm Name �'PQ w Date jaD 3
Permit COC OIC� NPDES (Rainbreaker PLAT Annual Cert Daily Pipe)
Lagoon Name, S forspillway
1
2
3
4
5
6
7
Design Freeboard 1 Last Recorded in
Observed freeboard
Sludge Survey Date
Jalain
Sludge Depth ft
Liquid Trt. Zone ft
3119
Ratio Sludge to Treatment Volume ifs 0.45
Date out of compliance/ POA?
gFT] 111111kY.T'GIL172
FZ
Soil Test Date Crop Yield \--"" Transfer Sheets
pH Fields Wettable Acres RAIN GAUGE
Lime Needed WUP Dead box or incinerator
Lime Applied Weekly Freeboard Mortality, Records'
Cu-I ___�,,Zn-I 1 in Inspections Check Lists
Needs S (S-1<25) 120 min Insp. Storm Water
Needs P Weather Codes
ri
, b,
1
RM
A
i �.1rJ1�i;���■
�-
Verify PHONE NUMBERS and affiliations
Date last WUP FRO I1&.leFRO or Farm Records
Date last WUP at farm Lagoon # ,
App. Hardware Top Dike 10)
Stop Pump R7=5"
Start Pump qq,�
4(p-8
Conversion- Cu-I 3000= 108 Iblac; Zn-I 3000= 213 Ib/ac q r�
. 15✓m*& 1 us�.e �,r 'n fir' 7 6" 0-rQ
415J cvp Jl� � — 1-5-

Type of visit: qj C ompiiance inspection U Vperation Review U structure itvaluation c J'l ecnnicat Assistance
Reason for Visit: Q Ifoutine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: A
Farm Name
Owner Name:
Mailing Address:
Physical Address:
Facility Contact:
Time: Departure Time:
. A
Email:
Phone:
Title: Phone:
Region:
Onsite Representative: Integrator: -�1 jlr,
Certified Operator: Certification Number:
Back-up Operator:
Location of Farm:
Latitude:
Certification Number:
Longitude:
Design Current Design Current
Swine Capacity I'ap. Wet Poultry Capacity Pop.
Wean to Finish La er
Cattle
DairyCow
Design
Capaeity
Current
Pop.
Wean to Feeder
Non -La er
DairyCalf
Feeder to Finish
DairyHeifer
arrow to Wean
Farrow to Feeder
Farrow to Finish
Design Current
Dr, Pt►ul_tr, C•_a acit P,p ..
Layers
D Cow
Non -Dairy
Beef Stocker
i
Gilts
Non -Layers
Beef Feeder
Beef Brood Cow
Boars
Pullets
Turke s
Turkey Poults
Other
Other
Other
Discharges 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?
❑ Yes [ to ❑ NA ❑ NE
❑ Yes ❑ No 21< ❑ NE
b. Did the discharge reach waters of the State? (if yes, notify DWQ) ❑ Yes ❑ No E5.4< ❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify 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 52 A ❑ NE
❑ Yes [�o ❑ NA ❑ NE
[:]Yes [ Vo ❑ NA ❑ NE
Page 1 of 3 21412011 Continued

Facility Number: - Date of inspection:
Waste Collection & Treatment /
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No jIA ❑ 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 L to ❑ 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
IL.d'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
�To
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
Poeo
❑ 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
0 Yes
To
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes g2o<o' ❑ NA
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s):
14. Do the receiving crops differ from those
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?
Reuuired Records & Documents
❑ Yes
❑ Yes
2"No ❑ NA
�o DNA
❑NA
❑ Yes �o
❑ Yes �o
❑ NE
[] NE
❑ NE
❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes 20N" o ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes ❑ 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 ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and t" Rainfall Inspections ❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes �o ❑ NA NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes ❑ No 21< ❑ NE
Page 2 of 3 21412011 Continued

Facili Number: jDate of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes �o ❑ NA ❑ NE
25. is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes gEr o ❑ 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 2<000 ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes ❑ No 5;; 3 A ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
❑ Yes g? o ❑ NA ❑ NE
❑ Yes 5; o ❑ NA ❑ NE
❑ Yes gfo ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes R24o ❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes E2 o ❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency? ❑ Yes PA<o' ❑ NA ❑ NE
Comments (refer to question #): Explain any YES answers andlor,any additional recommendations or anyFother;comments. 771
Use drawings of facility to better explain�situations (use additional pages as necessary)
A4,e�e�'
Reviewer/Inspector Name
Reviewer/Inspector
Page 3 of 3
Phone:
Date: 42A 7
21412011

Type of Visit: ommp�pliance Inspection Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: 0-1routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: ; / Departure Time: / County: Region:/lIL
Farm Name:<,'Wj'W 71' e�w_i�rmB� r!' �''/u► ('a�,�,�, Owner Email:
Owner Name: —�lY _��7�i^ - - -- -- Phone:
Mailing Address:
Physical Address:
Facility Contact: Sell Title: gza l Phone:
Onsite Representative: �� Integrator:-}^jH�,dryli
Certified Operator: S Certification Number: /G y�3
Back-up Operator: Certification Number:
Location of Farm:
Latitude: Longitude:
Design Current
Design
Current
Design Current
Swim'
.a icy Pop.
VHet Poultry
Capacity
Pnp,
Cattle Capacity Pop.
Wean to Finish
La er
Dairy Cow
Wean to Feeder
Non -La er
Dairy Calf
Feeder to Finish
Dairy Heifer
Farrow to Wean
Design
Current
Dry Cow
i..
Farrow to Feeder
Dr, Ppultr.,
C•_a aci
P;n ..
Non -Dairy
Farrow to Finish
Lavers
Beef Stocker
Gilts
Non -La ers
Beef Feeder
Boars
Pullets
Beef Brood Cow
1
Turke s
Others
Turkey Poults
Other
Other
�' �Si �.eM�aST3'iEiRi.=AS;P
3i .xYAk.ir'Vii�IL:.LYIW+i.:iLW
Y:.Y t.81kR89ASL
SY�:1d`.LtiS.f;K�i
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (if yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
❑ Yes to No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No
[—]Yes ® No
[]Yes ® No
❑NA ❑NE
❑ NA ❑ NE
❑ NA ❑ NE
Page I of 3 21412011 Continued

Facility Number: - Date of Ins ection: — D! Dj
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 ® No ❑ NA ❑ NE
Structure I 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?
(i.e., large trees, severe erosion, seepage, etc.)
Structure 5 Structure 6
❑ Yes ® No ❑ NA ❑ NE
6. Are there structures on -site which are not properly addressed and/or managed through a
❑ Yes
[,Z No
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health
or environmental threat,
notify DWQ
7. Do any of the structures need maintenance or improvement?
❑ Yes
m No
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
[]Yes
® No
❑ NA
❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require
❑ Yes
No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
[:]Yes
® No
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes [3 No ❑ NA [D 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): Ct2r' ✓t l duflrc�T �5�8ti/r,��r�LWi yl A;"_7�w 4 Ll a z /��►� ��r^/%t��®rtcy3�x
13. Soil Type(s): Ir'JF ZL-D& /Ll/-C
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? ayes Vo ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes I& 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 allo ❑ NA ❑ NE
❑ Yes [Z No ❑ NA ❑ NE
Reguired Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes 00 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 0 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 a No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 21412011 Continued

Facili Number: - Date of inspection: D%
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes allo ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes M No ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge?
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
Other Issues
2$. 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 tilt drains exist at the facility? If yes, check the appropriate box below
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
No
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
❑ Yes [a No ❑ NA ❑ NE
[:]Yes
® No
❑ NA
❑ NE
[3 Yes
[ZNo
❑NA
❑NE
[]Yes ® No
❑ Yes No
❑ Yes No
❑NA ❑NE
❑ NA ❑ NE
❑ NA ❑ NE
Comments (refer to question #): Explain any YES answers and/or any additional recommendations or any.other comments:
Use drawings of facility to better explain situations (use additional pitees as necessary). }" x
Reviewer/Inspector Name: � � � /d"'�- Phone: /r}—IaL 3392a
Reviewer/Inspector Signature: Date:
Page 3 of 3 21412011

Division of Water Quality
Facility Number I O Division of Soil and Water Conservation /A
O Other Agency
Type of Visit Compliance 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 ❑ Denied Access
Date of Visit: Arrival Time: (0 �� D Departure Time: County:CUz"6_e6L0&1 Region: F�X b
Farm Name: 'rr' //C Owner Email:
Owner Name: L=4iT�/" Phone:
Mailing Address:
Physical Address: �J
Facility Contact: K as:.,�i j d3//1p/`" Title: Phone No:
Onsite Representative: -_. _ .�(�� 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
Boars
0
Latitude: n
Back-up Certification Number:
❑ Longitude: = ° ❑ ' ❑
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer — --- - -
--- • I Non -Layer
Other
❑ Other
Dry Poultry
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ Turke
Puults
❑ Other
Discharses & 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
❑ Dairy Cow
❑ Dairy Calf
❑ Dairy Heifer
❑ Dry Cow
❑ Non -Dairy
❑ Beef Stocker
❑ Beef Feeder
❑ Beef Brood Cowl
I
Number of Structures: MJ
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
❑ Yes ® No ❑ NA ❑ NE
El Yes ❑No ❑NA ❑NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
Z,No
❑ NA
Cl NE
❑ Yes
EgNo
❑ NA
❑ 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?
a. If yes, is waste level into the structural freeboard?
Structure I Structure 2 Structure 3 Structure 4
❑ Yes SNo ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in): / G%
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
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
® 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
C$No
❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
5� No
❑ NA ❑ NE
maintenance/improvement?
. Is there evidence of incorrect application? If yes, check the appropriate box below.
[:]Yes
ZjNo
❑ 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 El Application Outside of Area
12. Crop type(s)
�1
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
Mv0
❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
®,No
❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ? ❑ Yes
[9 No ❑ NA ❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
59 No
❑ NA ❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
Z No
❑ NA ❑ NE
'Co mnients(refer to question; #) , Eiiplain any YESlanswers and/oriany recomrnendatlons or anygother,eomme ts.,
Use drawingsVfacility to better.'explam situahons.,(usefailditional pXXa s as necessary);( J,04,
L
Name Reviewer/Ins ector fi ,; t ° °� '}
p ��� .� . �� �*� Phone: -9`LQ7 �.3 3300
Reviewer/Inspector Signature: Date:
Page 2 of 3 12128104 Continued

h
Facility Number: Date of Inspection 3 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 RNo ❑ NA ❑ NE
the appropriate box. ❑ WUP ❑ Checklists ❑ Design El Maps [I Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes 99,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 ❑ Weather Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
RNo
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
[&No
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
®.No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
RNo
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
RNL o
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
8 No
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
allo
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
® No
❑ NA
❑ NE
and report the mortality raids that were higher than normal?
30.
At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
9 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
[9No
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
® No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
�&No
❑ NA
❑ NE
Additional Comments andlar llra►vin s ? y
YEA
,fix ` � F.
J
T
Page 3 of 3 12128104

Division of Water Quality
Facility Number Q Division of Soil and Water Conservation
O Other Agency
Type of Visit QOa�llance Inspection 0 Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit C Routine O Complaint O Follow up O Referral O Emergency Q Other ❑ Denied Access
Date of Visit: Arrival Time: ��(� Departure Time: 1 .1,9D County: /Region: ��
Farm Name: ll,_C Co Owner Email:
Owner Name: 19 Phone:
Mailing Address:
Physical Address: ��JJ
Facility Contact: &:,U si Title:
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Phone No:
Integrator:
Operator Certification Number: �G y33
Back-up Certification Number:
Latitude: 0 0 ❑ I = Longitude: = o
Design Current Design Current
Swine Capacity Population Wet Poultry Capacity Population
❑y - EEI
❑ N Non-- La er
❑ Wean to Finish
❑ Wean to Feeder
❑ Feeder to Finish
® Farrow to Wean (p00
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
Other
❑ Other
Dry Poultry
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ Turkey Poults
❑ 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
❑ Dairy Cow
UDxiryCalf
❑ Dad -Heifer
❑ Dry Cow
❑ Non -Dairy
❑ Beef Stocker
❑ Beef Feeder
❑ Beef Brood Cow
Number of Structures:
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
❑ Yes ®.No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
&4o
❑ NA
❑ NE
❑ Yes
®.No
❑ NA
❑ NE
12128104 Continued

F— Date of inspection
Facility Number:
i
Waste Collection & Treatment
4. is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes RNo ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Stnicture I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): O"
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes 19 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 ZNo ❑ 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 IRNo ❑ 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 ✓CVO ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes NNo ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes P5�No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or I o 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
ONo
❑ 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 acre determination? ❑ Yes
[3 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
0 No
❑ NA
❑ NE
Comments (refer to question ##): Explain any YES answers and/or any recommendations or any other comments.
Use drawings of facility to better explain situations. (use additional pages as necessary):
Reviewer/Inspector Name Phone:
Reviewer/Inspector Signature: Date:
12126104 Continued

Facility Number: d (p -- Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available?
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
the appropriate box.
❑ WUP El Checklists El Design [I Maps ❑Other
❑ Yes E[No ❑ NA ❑ NE
❑ Yes &No ❑ NA ❑ NE
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes SNo ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V 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? (ic/ 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
LqNo
❑ NA
❑ NE
❑ Yes
E�LNo
❑ NA
❑ NE
❑ Yes
ENo
❑ NA
❑ NE
❑ Yes
® No
❑ NA
❑ NE
❑ Yes
CgNo
❑ NA
❑ NE
❑ Yes
9No
❑ NA
❑ NE
❑ Yes
0 No
❑ NA
❑ NE
❑ Yes
® No
❑ NA
❑ NE
❑ Yes
5No
El NA
El NE
❑ Yes
[NNo
❑ NA
❑ NE
❑ Yes
&No
❑ NA
❑ NE
❑ Yes
EINo
❑ NA
❑ NE
12128104

Type of Visit 0 Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit 46 Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency /0 Other j ❑ Denied Access
�� : .t.1r�AP�(Gart on: FRO
Date of Visit: Arrival Time: � Q Departure Time: � County �.:�g'
i� ► : i� .'►i'�Ri�T•7I►/[f�T:MO RI:on, zu �7'1 loli'i �i.T�ffi1iRT�i.. ,T1 1 la
Owner Name: Phone:
Mailing Address:
Physical Address
Facility Contact: `J"IN04- Title: Phone No:
Onsite Representative: It Integrator: __,... 1 1 1
Certified Operator: I Operator Certification Number: ILL 33
Back-up Operator:
Location of Farm:
Back-up Certification Number:
Latitude: [= n ❑ Longitude: ❑ ° = , ❑
Wi.�Cap$acity Populaty�on. Wet Poultry Capacity Pap loti
Ues�ig�Current • Design CurrenrEDa
❑ Wean to Finish ❑ Layer
Design
Capacity
Current
Population
ow
❑ Wean to Feeder
❑ Non -La er
alf
❑ Feeder to Finish
❑ Dairy Heifer
Farrow to Wean Dry Poultry
❑ Farrow to Feeder
El Farrow to Finish ❑ Layers
❑ Gilts ❑ Non -Layers
❑ Boars ❑ Pullets
❑ Turkeys
Other .'.�t' : ❑Turke I'oults
❑ Other „ ❑ Other
❑ Dry Cow
ElNon-Dairy
❑ Beef Stocker
❑ Beef Feeder
❑Beef Brood Caw
Number of Structures:
Discharges & Stream Impacts
Is any discharge observed from any part of the operation? ❑ Yes 4
No ❑ NA ❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
❑ Yes
❑ No
q.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
I NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
jLNo
/A
❑ 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

j ►
Facility Number: — Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes PJNo ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No NA ElNE
Structure I Structure 2 Structure 3 Structure 4 Structure 5 tructure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): t
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes M 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 TNo ❑ 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 15%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 PNo ❑ NA ❑ NE
maintenance or improvement?
Waste_ Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes 1,No ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes J� No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 1 O lbs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of�Wind
�Drift
y0 Application OutsideofArea
12. Crop type(s) C$ry� 1 sTt b'Y`I`Orl l �t<iS-6i W a Gf iss UT�0 1sm� �tr• DAP
13. Soil type(s) ��r[Q11Y'Y�AV�`"C7y`I Dur ~IJh NB r� IL 1� l Wnti{3
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes 9No ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes 1� No ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?❑ Yes 1PNo ❑ NA ❑ NE
17. Does the facility lack adequate acreage for land application? ❑ Yes 0 No ❑ NA ❑ NE
18. Is there a lack of properly operating waste application equipment? ❑ Yes �j No ❑ NA ❑ NE
4-tv wt u`P-tr�G�` J lk-s
Reviewer/inspector Name c. ' " x Phone:
Reviewer/Inspector Signature: Date:
PQPe 2 al' i I 21281hd Continued

` 1
Facility Number: Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes V No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes C9 No ❑ NA ❑ NE
the approprrate box. ❑ WUp ❑ Checklists ❑ Design ❑Maps ❑Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes PNo ❑ 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 [gNo ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes E�No ❑ NA ❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
[�No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
OQ No
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
N3 No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
19 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
C9 No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
31.
Did the facility tail to notify the regional office of emergency situations as required by
❑ Yes
WNo
❑ 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
PO No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
(ANo
❑ NA
❑ NE
Additional Comments And/or Drawings ; � g ; � , ',s ,. ` « r. r �U 4 „ .
i
T
Page 3 of 3 12128104

Facility Number
10 Division of Water Quality
0 Division of Soil and Water Conservation
0 Other Agency
(Type of Visit IV Compliance Inspection O Operation Review 0 Structure Evaluation 0 Technical Assistance I
Reason for Visit *Routine 0 Complaint 0 Follow up O Referral O Emergency O Other ❑ Denied Access
Date of Visit: Arrival Time: 9= Departure Time: County
Farm Name: Owner Email:
Owner Name: Phone: _
Mailing Address:
Physical Address:
Region: P�
Facility Contact: V O%d 11V_ Title: I Phone No:
Onsite Representative: — _1CLzt.V�s` _ _ _ -„_ Integrator:
Certified Operator: �� Operator Certification Number:
Back-up Operator:
Location of Farm:
Swine
Wean to Finish
Wean to Feeder
Feeder to Finish
,Darrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Boars
Other
❑ Other
Back-up Certification Number:
Latitude: = c = f Q Longitude: = o = i =
gl
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer
❑ Non -La ar
Dry Poultry
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ Turkey Poults
❑ 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)
Design Current
Cattle Capacity .Population
❑
Dairy Cow
❑
Dairy Calf
❑
Dairy Heifei
❑
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: ID
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 hd No ❑ NA ❑ NE
❑ Yes
❑ No
NA
❑ NE
❑ Yes
❑ No
NA
❑ NE
❑ Yes
❑ No
NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
12128104 Continued

r
Facility Number: —�
Date of Inspection
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
Identifier:
Spillway?: Q
Designed Freeboard (in): (!
Observed Freeboard (in): 3117
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 �4o ❑ NA ❑ NE
❑ Yes �I No ❑ 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
`VNo El NA El NE
8. Do any of the stuctures lack adequate markers as required by the permit? El Yes `�,Q No ElNA [I NE
(Not applicable to roofed pits, dry stacks and/or wet stacks) I
9. Does any part of the waste management system other than the waste structures require ❑ Yes [ANo ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
maintenance/improvement?
❑ Yes "I*o ❑ NA ❑ NE
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes KNo ❑ 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 Win Drift ❑ Application Outside of Area
ac
12. Crop type(s) G„r
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWNW?
❑ Yes
XNo
15. Does the receiving crop and/or land application site need improvement'?
❑ Yes
M No
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?❑ Yes
�CNo
17. Does the facility lack adequate acreage for land application?
❑ Yes
No
18. Is there a lack of properly operating waste application equipment?
❑ Yes
N,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 additional pages as necessary):
Reviewer/Inspector [Name .
❑NA ❑NE
[I NA El NE
[I NA ❑NE
El NA ❑NE
Reviewer/Inspector Signature:
Date: ijA
12128104
1
Continued

r . • %;
Facility Number: k, Date of Inspection [�o
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes ANo ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes )@ No ❑ NA ❑ NE
the appropirate box. ❑ WUP ❑ Checklists ❑ Design ❑Maps El Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes Pq 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 ANo ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes :1 No XNA ❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
1,No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
❑ No
[ANA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
�To
/D
❑ NA
El NI,
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
DZNo
❑ 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
❑ YesVo
El NA
❑ NE
General Permit? (iel discharge, freeboard problems, over application)
32.
Did Reviewer/inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
KZ No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes�zo
❑ NA
❑ NE
Additional Comments and/or Drawings:
am, 4"o UPI(_ cr �I�� A oh
12128104

Facility No, CIAU Time In 1 Time Out Date I
4 Farm Nam '_r4.d'yw.4i Integrator
Owner Site Re
IIp--�� {{,,
Operator i �/ No,
Back-up No.
COC Circle General or NPDES
Design
Current
Design
Current
Wean = Feed
Farrow - Feed
Wean - Finish
Farrow - Finish
ins
Gilts / Boars
Farrow - W
Others
FREEBOARD: Design Observed
Sludge Survey Calibration/GPM✓ ( ! a�
Crop Yield Waste Trangftrs
Rain Gauged Rain Bre cer
Soil Test �' PLAT Wettable Acres ;r
Weekly Freeboard Daily Rainfall 1-in Inspections
Spray/Freeboard Drop
Weather Codes
Waste Analysts:
120 min Inspections
Date Nitrogen (N)
Date Nitrogen (N)
w.
i
I

Type of Visit
Compliance Inspection
0 Operation Review 0 Structure Evaluation
0 Technical Assistance
Reason for Visit
0 Routine 0 Complaint
0 Follow up 0 Referral 0 Emergency
0 Other ❑ Denied Access
Date of Visit: .- Arrival Time: Departure Time: 1 311,3-County: ezi Region: D
Farm Name: r;� m2nj 0U.1 LmewL" � �t�ctar�Y/ 1��°• /,
i Owner Email:
Owner Name: &_'ndv M r- Phone:
Mailing Address:
Physical Address: 1
Facility Contact: /�N:ildV . Title:
Onsite Representative: _ j 0::U :r--.
Certified Operator: :izw e - -
Back-up Operator:
Location of Farm:
Phone No:
Integrator:,- rr i vt yy
Operator Certification Number:
Back-up Certification Number:
Latitude: 0 0 = = " Longitude: = ° = 4 0 "
Design Current Design Current
Swine Capacity Population Wet Poultry Capacity Population
❑ Wean to Finish
❑ Wean to Feeder
❑ Feeder to Finish
❑ Farrow to Wean I D
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
Other
❑ Other
� ❑ Layer E�d
❑ Non -Layer
Dry Poultry
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ Turkey Poults
❑ Other
Discharges & 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?
Design Current
Cattle Capacity Population
❑
Dairy Cow
❑
Daia Calf
❑
Dairy Heifer
❑
Dry Cow
❑
Non -Dairy
❑
Beef Stocker
❑
Beef Feeder
❑
Beef Brood Cow
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)?
Number of Structures:
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
❑ Yes ,Q No ❑ NA ❑ NE
❑ Yes
P4 No
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
ElNA
ElNE
❑ Yes
/401 No
❑ Yes
,ro No
❑ NA
❑ NE
❑ Yes
[XNo
❑ NA
❑ NE
12128104 Continued

;--. . 'i�
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
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
(9No
❑ NA
❑ NE
Structure l Structure 2 Structure 3 Structure 4
Structure
5
Structure 6
Identifier:
Spillway?:
Designed Freeboard (in): 19
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
X 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
ZI 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?
29 Yes
❑ No
❑ NA
❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes M 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 JANo ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes J�jNo ❑ 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 Drif! ❑ 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
JRNo
❑ 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
&No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
R1 No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
C&No
❑ NA
❑ NE
WVr k ,.Tft s and s7�dl �� w r-a k
6V r I[IYiLJ f�Gi`YS /1 p r S C.0 jU V -VzV m u,Zt. 7flj W, Ze SXXJ
Reviewer/Inspector Name I I. y,, .rro Phone;
Reviewer/Inspector Signature: Date: 3 41-Vc�
1212VO4 Continued

Facility Nurnber:,•21,— Date of Inspection — 3
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes allo ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes KNo ❑ NA ❑ NE
the appropirate box.
❑ WUP El Checklists El Design El Maps ❑Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes �KNo ❑ 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 ❑ Weather Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
r'71 No
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
�o
[ZNA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
IN No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
OZNo
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
M No
❑ NA
El NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
❑ No
I,NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
rVINo
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
PNo
❑ 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
JQ 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
[INA
[INE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
J@ No
❑ NA
❑ NE
Acltlitional�Ca�rernents�'and/nr'Drawings�'�,,°V.�;,�`°,�'
12128104
12128104

,
Facility• Number
Date of Vicit: Time.
Nat O eratinnal Belnw Threshold
® Permitted ® Certified 0 Conditionally Certified [3 Registered Hate Last Operated or Above Threshold:
Farm Name: County. ._ C�(I'L.- erjd_v.'- �
•
Owner Name: Phone No: q A I bgci
Mailing Address: 2DR0 '« 2DC'a _.�� ,�, Q�c.� Mc,
Facility Contact: I Q u rVf —Title: _ Title: Phone No:
Onsite Representative: Integrator: STQ.,P�
Certified Operator: _ iz� T� rsr���_ _ Operator Certification Dumber: 164,33
Location of Farm: Q
MSwine ❑ Poultry ❑ Cattle ❑ Horse Latitude Longitude
Design Current
Design Current Design Current
Swine Capacity Population
Poultry
capacity Population Cattle CaiDecitv Population
❑ Wean to Feeder
JE1 Laver
I
I
Dairy
❑ Feeder to Finish
❑ Non -Laver
EoNon-Dairy
® Farrow to Wean
O
Farrow to Feeder
❑ether
❑ Farrow to Finish
Total Design Capacity
❑ Gilts
❑ Boars
Total SSLW
Number of Lagoons F ❑ Subsurface Drains Preient ❑ La oon Area spray Field Area
F: Holding Ponds /Solid Traps ` .. ❑ No LAuld Waste Management System
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation? ❑ Yes [5a No
Discharge originated at: ElLagoon ElSprav Field ElOther
a. If discharge is observed, was the conveyance man-made? ❑ Yes ❑ No
b. if discharge is observed, did it reach Water of the State? (if yes, notify DWQ) ❑ Yes ❑ No
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 ❑ No
2. is there evidence of past discharge from any part of the operation? ❑ Yes ®.No
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes ® No
Waste Collection & Treatment
4. is storage capacity (freeboard plus storm storage) less than adequate? M Spillway ❑ Yes 0 No
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Freeboard (inches): �5
05103101 Continued

Facility Number: . 4, — I j Date of Inspection
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, ❑ Yes M No
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or
closure plan? (if any of questions 4-6 was answered yes, and the situation poses an ❑ Yes ® No
immediate public health or environmental threat, notify DWQ)
7. Do any of the structures need maintenance/improvement? ❑ Yes � No
8. Does any part of the waste management system other than waste structures require maintenance/improvement? ❑ Yes ® No
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings? ❑ Yes No
Waste-AUglication
10. Are there any buffers that need main tenancelimprovement? ❑ Yes No
11. Is there evidence of over application? ❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload ❑ Yes No
12, Crop typetcco y
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)? ❑ Yes No
14. a) Does the facility lack adequate acreage for land application? ❑ 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 ® No
16. Is there a lack of adequate waste application equipment? ❑ Yes [3 No
Rcouired Records & Documents
17.
Fail to have Certificate of Coverage & General Permit or other Permit readily available?
❑ Yes
P No
18.
Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ic/ WUP, checklists, design, maps, etc.)
❑ Yes
R No
19.
Does record keeping need improvement? (ie/ irrigation, freeboard, waste analysis & soil sample reports)
❑ Yes
® No
20.
Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
Q No
21,
Did the facility fail to have a actively certified operator in charge?
❑ Yes
[�l No
22.
Fail to notify regional DWQ of emergency situations as required by General Permit?
(ie/ discharge, freeboard problems, over application) ❑ Yes CONo
23. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative? ❑ Yes P1 No
24. Does facility require a follow-up visit by same agency? ❑ Yes P,No
25, Were any additional problems noted which cause noncompliance of the Certified AWMP? ❑ Yes [RNo
0 No violations or deficiencies were noted during this visit. You will receive no further correspondence about this visit.
Cinmentsa(irefer to,gtie`stio t #)4 l lain any YES'answers and/or any recommcndationspi an{ other comments . i ��'
i""r adm ,a 'l aw nF ul 4�`
`Use druwings of facilityo better explain situations. (use additional pal;( a necessary)r ❑ Field Copy ❑ Final Notes
-GI`✓� jJ� �� �e +� v..., •- I`e CD rd�j , I.." o [cad lrn CX _
Reviewer/]nspector Name I
Reviewer/inspector Signature:
Date:
05103101 1 1 Continued

Facility Number: ,2 (p —1� Date of inspection 5
Colo lam
26. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of properly within 24 hours?
28. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt,
roads, building structure, and/or public property)
29. Is the land application spray system intake not located near the liquid surface of the lagoon?
30. Were any major maintenance problems with the ventilation fan(s) noted? (i.e. broken fan belts, missing or
or broken fan blade(s), inoperable shutters, etc.)
31. Do the animals feed storage bins fail to have appropriate cover?
32. Do the flush tanks lack a submerged fill pipe or a permanent/temporary cover?
❑ Yes No
❑ Yes No
❑ Yes ® No
❑ Yes @ No
❑ Yes ® No
El Yes (DNo
❑ Yes ❑ No
05103101

® Permitted ® Certified O Conditionally Certified © Registered Date Last Operated or Above Threshold-,
Farm lame: County: ct. n/157s('�GM�'X
Owner Name: A n - _l Phone No:
i
P, Mailing Address: 4 (� i i 1�ri _t _ PYI i �� _ o CA
Facility Contact: Title: a t&� - Phone No:
Onsi#e Representative: Integrator: _ },i] r►Pi n Lblj &mns
Certified Operator: y 4kp f'-- Operator Certification number:
Location of Farm:
40-Swine ❑ Poultry ❑ Cattle ❑ Horse Latitude r.�• ' 0 u Longitude ' 1 K
Design Current Design Current Design Current
Swine Capacity Population Poultry Capacity Population Cattle Capacity Population
❑ Wean to Feeder I ID Laver I I❑ Dai
❑ Feeder to Finish I JEJ Non -Layer I I Non-Dairy
® Farrow to Wean (3
Farrow to Feeder 10Other
❑ Farrow to Finish Total Design Capacity
❑ Gilts
❑ Boars Total SSLW
' Number of Lagoons j ' s. ❑Subsurface Drains Present ❑ La oon Area
�NHolding Ponds I Solid Traps 0 ''.. JEJ No Liquid Waste Mara ement System
Discharges S tre cts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Lasoon ❑ Spray Field ❑ Other
a. if discharge is observed, was the conveyance man-made?
b. if discharge is observed, did it reach Water of the State? (if yes, notify DWQ)
c. if discharge is observed, what is the estimated flow in gaUmin?
d. Does discharge bypass a lagoon system? (If yes, notify DWQ)
2. Is there evidence of 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?
Waste Collection & Irgatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway
Structure I Structure 2 Structure 3 Structure 4 Structure 5
Identifier:
Freeboard (inches): f
05103101
( No
❑ Yes
❑ Yes
❑ No
❑ Yes
❑ No
❑ Yes
❑ No
❑ Yes
51 No
❑ Yes
® No
❑ Yes
C9 No
Structure 6
Continued

Facility Number: — Date of inspection
5. Are there any immediate threats to the integrity of any of the structures observed? (icl trees, severe erosion, ❑ Yes 3No
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or
closure plan? (If any of questions 4-6 was answered yes, and the situation poses an ❑ Yes [3 No
immediate public health or environmental threat, notify DWQ)
7. Do any of the structures need maintenance/improvement? ❑ Yes RNo
8. Does any part of the waste management system other than waste structures require maintenance/improvement?
❑ Yes
U&No
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings?
❑ Yes
CRNo
Waste pplication
10, Are there any buffers that need maintenancelimprovement?
❑ Yes
M No
TV
11. Is there evidence of over application? ❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload
❑ Yes
[�RNo
12. Cro t e �, S-
p Yp , .,..,...r� ef'✓vz i..F�_ � .... c.QQ___�st�'G.c,%...� ..
_
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)?
❑ Yes
19No
14. a) Does the facility lack adequate acreage for land application?
❑ Yes
❑ No
h) 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
No
16. Is there a lack of adequate waste application equipment?
❑ Yes
No
Required Records & Document!
17,
Fail to have Certificate of Coverage & General Permit or other Permit readily available?
❑ Yes
i9 No
18.
Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.)
❑ Yes
® No
19.
Does record keeping need improvement? (iel irrigation, freeboard, waste analysis & soil sample reports)
❑ Yes
MNo
20.
Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
A No
21.
Did the facility fail to have a actively certified operator in charge?
❑ Yes
W No
22.
Fail to notify regional DWQ of emergency situations as required by General Permit?
❑ Yes
® No
(ic/ discharge, freeboard problems, over application)
23.
Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes
J,No
24.
Does facility require a follow-up visit by same agency?
❑ Yes
[it No
25.
Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
QlNo
10 No violations or deficiencies were noted during this visit. You will receive no further correspondence about this visit.
C mentsn(refer to quegtlo ` #) ""Eipliin any YES answers anWdir any recommendations or any other cot%
Use drawings of facility to better explalnAtuations .(use,aadditional pages as necessary,) �' ?� �Y pinal Notes h '
rt El Field Copv ❑
�.r.
f\cczr Jo
Reviewer/inspector Name
Reviewerlinspector Signature: Date., 4
O5103101 Continued

1 i
Facility Number: 4- Iq Date of Inspection O a 0
Odor issues
26. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of properly within 24 hours?
28. Is there any evidence of wind drift during land application? (Le, residue on neighboring vegetation, asphalt,
roads, building structure, and/or public property)
29. Is the land application spray system intake not located near the liquid surface of the lagoon?
30. Were any major maintenance problems with the ventilation fan(s) noted? (i.e. broken fan belts, missing or
or broken fan blade(s), inoperable shutters, etc.)
31. Do the animals feed storage bins fail to have appropriate cover?
32. Do the flush tanks lack a submerged fill pipe or a permanent/temporary cover?
05103101
❑ Yes ❑ No
❑ Yes R] No
❑ Yes Z No
❑ Yes 2 No
❑ Yes ® No
❑ Yes ® No
❑ Yes [:]No

Site Requires Immediate Attention:
Facility No.
DIVISION OF ENVIRONMENTAL MANAGEMENT
ANIMAL FEEDLOT OPERATIONS SITE VISITATION RECORD
DATE: B , 1995
Time:
Farm Name/Owner: P . 2. 1-4,.,q cloy d~ _s
Mailing Address: :2Q -73
County:_ .�/d,,4 -L
Integrator: 5prW4 Phone:
On Site Repre tative: PA, / Z-4-0"IYA011 Phone:
Physical Address/Location:
Type of Operation: Swine �� Poultry Cattle
Design Capacity: _rQ ce�.ea _ Number of Animals on Site:
DEM Certification Number: ACE DEM Certification Number: ACNEW
Latitude: 0 Longitude: "
Circle Yes or No
Does the Animal Waste Lagoon hr e sufficient freeboard of 1 Foot + 25 year 24 hour storm event
(approximately 1 Foot + 7 inches) Yor No Actual Freeboard: - Ft._-L-Inches
Was any seepage observed from the lagoon(s)? Yes or ® Was any erosion observed? Yes or®
Is adequate land available for spray? ie or No Is the cover crop adequate? Yes or No
Crop(s) being utilized:
Does the facility meet SCS minimum setback criteria? 200 Feet from Dwellin or No
' 100 Feet from Wells? or No
Is the animal waste stockpiled within 100 Feet of USGS Blue. Line Stream? Yes or 49
Is animal waste land applied or spray irrigated within 25 Feet of a USGS Map Blue Line: Yes or(O
Is animal waste discharged into water of the state by man-made ditch, flushing system, or other
similar man-made devices? Yes or 10 If Yes, Please Explain.
Does the facility maintain adequate waste management reco (volumes of manure, land applied,
spray irrigated on specific acreage with cover crop)? W&Oor No
Signature'
cc: Facility Assessment Unit Use Attachments if Needed.

State of North Carolina
Department of Envird`-nent,
Health and Natural R6.zources
Division of Envfronmental Management
James B. Hunt, Jr., Governor
Jonathan B. Howes, Secretary
A. Preston Howard, Jr., P.E., Director
AN
t
4 D
IN 995
"NfNAGEMENT
FAYETrEVILLE REG. OFFICE
INSTRUCTIONS FOR CERTIFICATION OF APPROVED ANIMAL WASTE MANAGEMENT PLANS FOR
NEW OR EXPANDED ANIMAL WASTE MANAGEMENT SYSTEMS SERVT14G FEEDLOTS
In order to be deemed permitted by the Division of Environmental Management
(DEM), the owner of any new or expanded animal waste management system
constructed after January 1, 1994 which is designed to serve greater than or
equal to the animal populations listed below is required to submit a signed
certification form to DEM y,af2r9 the new animals are stocked on the farm.
Pasture operations are exempt from the requirement to be certified.
100 head of cattle
75 horses
250 swine -
1,000 sheep
30,000 birds with a liquid waste system
The certification must be signed by the owner of the feedlot (and manager if
different from the owner) and by any technical specialist designated by the Soil
and Water Conservation Commission pursuant to 15A NCAC 6F .0001-.0005. A
technical specialist must verify by an on -site inspection that all applicable
design and construction standards and specifications are met as installed and
that all applicable operation, and- maintenance standards and specifications can
be met.
Although the actual number of animals at the facility may vary from time to time,
the design capacity of the waste handling system should be used to determine if
a farm is subject to the certification requirement. For example, if the waste
system for a feedlot is designed to handle 300 hogs but the average population
will be 200 hogs, then the waste management system requires a certification.
This certification is required by regulations governing animal waste management
systems adopted by the Environmental Management Commission (EMC) on December 10,
1992 (Title 15A NCAC 2H .0217).
On the reverse side of this page is the certification form which must be
submitted to DEM before new animals are stocked on the farm. Assistance in
completing the form can be obtained from one of the local agricultural agencies
such as the soil and water conservation district, the USDA -Soil. Conservation
Service, or the N.C. Cooperative Extension Service. The form should be sent to:
Department of Environment, Health and
Division of Environmental Management
Water Quality Section, Planning Branch
P.O. Box 29535
Raleigh, N.C. 27626-0535
Phone: [phone]
Form ID: ACNEW0194
Natural Resources
Steve W. Tedder, Chief
Water Quality Section
Date: &_ _ 7J. /Ss3
PA. Box 29535, Roieigh, North Caroiir..1.27626-0535 Telephone [phone] FAX [phone]
An Egud Opportunity Atalirmotive Action Employer 50%recycled/ 10% post -consumer paper

AxnmS WASTE PLAN CERTIFYCATION FOR NEW OR EXPANDED FEWLOTS
Please retu= the comyleted form to the Division of Environmental Management at
the address oa the reverse sidr of this form.
Name of f (P se rint): G
Address:
Phone o.:
County:
Farm location: Latitude and Long itude.Q.T)a &"./W !Le &" (required) . Also,
please attach a copy of a county road map with_.;Location identified.
Type of operation (swine, layer, dairy, t }; e
Design capacity (number of animals):✓ W O
Average size of operation (12 month population ayg.):gId4
Average acreage needed for land application of waste (acres):
' oassaaaaaassaaaaaaaaRaaaamaaaaaaaaaaaaaaaaraaaaaaaaaarxwaaaaaaaaaaaaaaisaaaaaaaaaeaa
Technical Specialist Certification
As a technical specialist designated by the North Carolina Soil and water
Conservation Commission pursuant to 1SA NCAC 6F .0005, I certify that the new or
expanded animal waste management system as installed for the farm named above
has an animal waste management plan that meets the design_, construction,
operation and maintenance standards and specifications of the Division of
Environmental Management and the USDA -Soil Conservation Service and/or the North
Carolina Soil and Water Conservation Commission pursuant to 15A NCAC 2H.0217 and
15A NCAC 6F .0001-.0005. The following elements and their corresponding minimum
criteria -haves been verified by me or other designated technical specialists and
are included in the plan as applicable: minimum separations (buffers); liners or
equivalent for lagoons or waste storage ponds; waste storage capacity; 'adequate
quantity and amount of land for waste utilization (or use of third party); access
or ownership of proper waste application equipment; schedule for timing of
applications; application rates; loading rates; and the control of the discharge
of pollutants from stormwater runoff events, less severe than the 25-year, 24-hour
storm.
Name of Technical Specialist (Please rint} : , -Ooj M. -A-el JA,
Affiliation: o44L_ ty vc ,
Address (Agency) : 7,( MouvrAss- #A 7,21 Phone No.:2/6 --YAY-.SSj'
FA I_Nc- ZP 3 v
Signature: Date,
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Owner/Hanag Agreement
I (we) understand the operation and maintenance procedures established in the
approved animal waste management plan for the farm named above and will implement
these procedures. I (we) know that any additional expansion to the existing
design capacity of the waste treatment and storage system or construction of new
facilities will require a new certification to be submitted to the Division of
Environmental Management before the new animals are stocked. I (we) also
understand that there must be no discharge of animal waste from this system to
surface waters of the state either through a man-made conveyance or through
runoff from a storm event less severe than the 25-year, 24-hour storm. The
approved plan will be filed at the farm and at the office of the local Soil and
Water Conservation District.
Name of Land owner (Please $tint) : fir/` A,'
Signature: / Date:
Name of Hanagar, if different from owner (Please print):—
G•
gnatuxe: • Date:
tg: A change in land ownership requires notification or�a new certification
f the approved plan is changed) to be submitted to the Division of
vironmental Management within 6o days of a title transfer.
DE4 USE ONLY:ACNEW#