820210_INSPECTIONS_20171231

NUH I H UAHULINA
Department of Environmental Qua]

Type of Visit: 40 Compliance Inspection 0 Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit: m Routine O Complaint Q Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact: :122 Iv iYG y_eJ Title:
Onsite Representative: L
Certified Operator:
Back-up Operator:
ime• E�County: Region: FAV
Owner Email:
Phone:
Phone:
Integrator:«1�1
Certification Number:
Certification Number:
Location of Farm: Latitude: Longitude:
Design 'current
Design
Current
Design Current
Swine
Capacity y Pop.
Wet tout try
C►apaci#y
Pop.
Cattle
Capacity Pop.
Wean to Finish
airy Cow
Wean to Feeder
Non -La er
Dairy Calf
Feeder to Finish
Dairy Heifer
Farrow to Wean
D , Panl
Design
Ca aci
Current
P.o
Dry Cow
Farrow to Feeder
Non -Dairy
Farrow to Finish
Layers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
I 113eef Brood Cow
Pullets
r�
Turkeys
Other __;
TurkeyPoults
Outer
Other
Dischar es and Stream Im acts
1. is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWR)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWR)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
❑ Yes CpNo ❑ NA ❑ NE
❑ Yes
❑ No
[TNA
❑ NE
[:]Yes
[:]No
Q9 NA
❑ NE
❑ Yes
❑ No
❑ Yes
No
❑ Yes
No
MNA
❑NE
❑NA
❑NE
❑NA
❑NE
Page I of 3 21412015 Continued

Facili Number: Z Date of Ins ection: b Z
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 ftNA ❑ 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�FNo ❑ NA ❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a ❑ Yes No ❑ NA ❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWR
7. Do any of the structures need maintenance or improvement? ❑ Yes No ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes No ❑ NA ❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes P 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 Acce table Crop Window ❑ Evidence Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s): G�ci' qLas, IL
13. Soil Type(s): b -
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 [ r� 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
r!�No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? if yes, check
❑ Yes
[P No
❑ NA
❑ NE
the appropriate box.
T
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below_ ❑ Yes l T No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 21412015 Continued

Facility Number: Date of Ins ection-
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes rQ No
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check [] Yes No
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
0 Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge? ❑ Yes No
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes 2 No
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
34. Does the facility require a follow-up visit by the same agency?
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
❑ Yes No
❑ Yes No
❑ Yes No
❑ Yes No
❑ Yes No
❑ Yes No
❑ Yes [F No
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑NA ❑NE
Phone: v
Date: 7 a
21412015

II ype of Visit: a Compliance inspection V Vperatlon Keview u structure Evaluation V l ectinical Assistance
Reason for Visit: Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: + l ' Arrival Time: ` t?D Departure Time: p ADO County: s Region:
Farm Name: {yQ,,, `�`' Owner Email:
Owner Name: �t �c,,Phone:
Mailing Address:
Physical Address:
Facility Contact: 7;�>o Title: Phone:
Onsite Representative: 4
[( Integrator: 5ktkop i }-{
Certified Operator: - 1 Certification Number: l b ISO
Back-up Operator: Certification Number:
Location of Farm: Latitude: Longitude:
Design Current
Swine 'Capacity Pop. Wet Poultry
Wean to Finish Layer
Design Current
Design Current�JG
Capacity Pop. CaapacityPop.
Dairy Cow
Wean to Feeder
Non -Layer
D . Poultr
Layers
Dairy Calf
Feeder to Finish
Design Current
Ca aci Po
Dairy Heifer
D Cow
Non -Dairy
Beef Stocker
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
on -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Othe
Turke s
ey Poults
Other
Other
DischaEges 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)
❑ Yes 1� No ❑ NA ❑ NE
❑ Yes ❑ No
❑ Yes ❑ No
NA ❑ NE
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 n NA ❑ NE
2. Is there evidence of a past discharge from any part of the operation? ❑ Yes EP No ❑ NA ❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters ❑ Yes No ❑ NA ❑ NE
of the State other than from a discharge? 91
Page I of 3 21412015 Continued

[Facility —Number: C Date of Inspection: 0
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
P No
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No
4NA
❑ 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
a] No
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat,
notify DWQ
7. Do any of the structures need maintenance or improvement?
❑ Yes
No
❑ NA
❑ NE
$. 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
�5 No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
MNo
❑ NA
❑ NE
maintenance or improvement?
r,
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 rift �r ❑ Application Outside of Approved Area
12. CropT e s : �a5S J%I'{r
YP () — ice^- � �1--v 6' �' 1 -t t
13. Soil Type(s): 1\1 w4o V -00
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
Re uired Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
No
[] NA
❑ NE
the appropriate box.
❑WUP ❑Checklists [:]Design [:]Maps ❑ Lease Agreements ❑Other.
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes j 1 No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes � No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes W No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 21412011 Continued

Facili Number: Date of Ins ectlon: Ino
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 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
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
�o
❑ NA
❑ NE
❑ Yes
P No
❑ NA
❑ NE
❑ Yes
VNo
❑ NA
❑ NE
❑ Yes No ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
❑Yes �No ❑NA ❑NE
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes T?No ❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes No ❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency? ❑ Yes No ❑ NA ❑ NE
Comments (refer to question ft Explain any YES answers and/or any additional recommendations or any other comments.
Use drawines of facility to better explain situations (use additional panes as necessarv). o
Reviewer/inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: ��v�3 3- 33�' 33�
Date: hOZ
21412015

Type of Visit: ® Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: 40 Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: O Departure Time: County: IQ' Region: Imo`
Farm Name: t V D A.t1b Owner Email:
Owner Name: 914 Phone:
Mailing Address:
Physical Address:
Facility Contact:] ? Title: Phone:
Onsite Representative: Integrator: Jt _dd
Certified Operator: l Certification Number:
Back-up Operator: Certification Number:
Location of Farm: Latitude: Longitude:
jimDesign
Current
Design
Current
Design Current
Swine
Capacity Prop.
Wet Poultry
Capacity
Pop.
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
Farrow to Feeder
D , P,oul
Ca aci
P,o .
Non -Dairy
Farrow to Finish
La ers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
I
113eef Brood Cow
_
Turkeys
Other
Turkey 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?
b. Did the discharge reach waters of the State? (If yes, notify DWR)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWR)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
❑ Yes 99 No ❑ NA ❑ NE
❑ Yes
❑ No
n NA
❑ NE
❑ Yes
❑ No
T NA
❑ NE
❑ Yes ❑ No
❑ Yes No
❑ Yes No
NA
❑ NE
❑NA
0. NE
❑ NA
❑ NE
Page I of 3 21412015 Continued

Facili 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 .V NA
❑ NE
Structure I Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier: �^
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
/[�] No ❑ NA
❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
IT
6. Are there structures on -site which are not properly addressed and/or managed through a
❑ Yes
No ❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWR
7. Do any of the structures need maintenance or improvement? ❑ Yes [nNo ❑ NA ❑ NE
8. Do any of the structures 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 [P No ❑ NA ❑ NE
maintenance or improvement?
Waste Aaalication
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes ( No ❑ NA ❑ NE
maintenance or improvement? TT
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes ro ❑ 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 Acceptably Crop Window _ ❑ Fidence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s): �"` • (}Ci
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
y
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
D Yes
® No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
® No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
No
❑ NA
❑ NE
the appropriate box.
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soii Analysis ❑ Waste Transfers ❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V 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 M No ❑ NA ❑ NE
Page 2 of 3 21412015 Continued

Facili Number: IDate of inspection: /
24.'Did the'facility fail to calibrate waste application equipment as required by the permit? ❑ Yes No
25. is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes No
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a PGA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge? ❑ Yes No
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes No
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
34. Does the facility require a follow-up visit by the same agency?
Reviewer/Inspector Name:
Reviewer/Inspector Signatur
Page 3 of 3
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ Yes [P No ❑ NA ❑ NE
❑ Yes % No ❑ NA ❑ NE
❑Yes �No ❑NA ❑NE
❑ Yes ® No ❑ NA ❑ NE
❑ Yes No
❑ Yes No
❑ Yes No
❑NA ❑NE
❑ NA ONE
NE
❑ NA ❑ NE
mments.
Phone: I to-43?`33do
Date:
21412015

Type of Visit: ® Compliance Inspection O Operation Review Q Structure Evaluation O Technical Assistance
Reason for Visit: qj Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access �y�
Date of Visit: t Arrival Time: �00� Departure Time: County: s4^' Region{, "b
Farm Name: AV, &_ (.a+^-90 POP-4 �'� Owner Email:
r �
Owner Name: �� Phone:
Mailing Address:
Physical Address:
Facility Contact:
Onsite Representative: ]
Certified Operator:
Back-up Operator:
Location of Farm:
Title:
Latitude:
Phone:
Integrator:
Certification Number:
Certification Number:
Longitude:
Design Current Design Current
Swine Capacity Pop. \Vet Poultry Capacity Pop.
Design Current
Cattle Capacity Pop.
Wean to Finish
s
Layer
Dai Cow
Wean to Feeder
Non -Layer
Dai Calf
Feeder to Finish
Farrow to Wean
2XgD
Design Current
Dr. P,ouI Ca aci P,o .
Dairy Heifer
Dry Cow
Farrow to Feeder
Non -Dairy
Farrow to Finish
Layers
Beef Stocker
Gilts Non -La ers
Boars Pullets
Turkeys
Other Turkey Poults
Beef Feeder
Beef Brood Cow
Other Other
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (if yes, notify DWR)
c. What is the estimated volume that reached waters of the State (gallons)?
[:]Yes jQNo ❑ NA ❑ NE
[:]Yes [:]No
[:]Yes [:]No
NA ❑ NE
NA ❑ NE
d. Does the discharge bypass the waste management system? (If yes, notify DWR) [:]Yes ❑ No EP
NA ❑ NE
2. Is there evidence of a past discharge from any part of the operation? ❑ Yes 0 No ❑ NA ❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters ❑ Yes ERNo ❑ NA ❑ NE
of the State other than from a discharge?
Page I of 3 21412014 Condnued

Facili Number: Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
[?g�No
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No
E§)NA
❑ NE
Structure I Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): 21
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
No
❑ NA
❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a
❑ Yes
No
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat,
notify DWR
7. Do any of the structures need maintenance or improvement?
❑ Yes
P 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
n No
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes P No ❑ NA ❑ NE
[:3'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 Cro Window Evidenc [,Wind Drift ❑ Applicatiion Outside of Approved Area
�t,- 12. Crop Type(s): S &z S /?. � % 6ZZ &oa_e
13. Soil Type(s): [ V o
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
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 F
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 9No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 21412014 Continued

Facili dumber: - Date of Ms ection: N
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
[P No
❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check
❑ Yes
P No
❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of fast 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
No
❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
[!9 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
Iq No
❑ NA ❑ NE
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
❑ Yes
b] No
❑ NA ❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface file drains exist at the facility? If yes, check the appropriate box below.
❑ Yes
No
❑ NA ❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
No
❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
O No
❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
IN No
❑ NA ❑ NE
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: t a- r
Date: I't ht
214 O14

iype of visit: w uompnance inspection v uperanon xeview tv structure tvatuanon u teennical Assistance
Reason for Visit: ® Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: 'r I Arrival Time: Ln Departure Time: County: Region:F-90
Farm Name: qpL>sv►d 30I Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact:
Af�wS �j tl- . fn Title:
`_111�_
Onsite Representative: `Z t
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Phone:
Integrator:
Certification Number:
Certification Number:
Longitude:
Dese n Current' g .Desigii
.vim
Current
Design Current
Swine
Capacity Pop.
Wet Ponitry
Capacity
Pop.
Cattle Capacity Pop.
rim:-
Wean to Finish
Layer
Dairy Cow
Wean to FeederRINon-Layer
Dairy Calf
Feeder to Finish
O
-
Dairy Heifer
Farrow to Wean
Design
Current
D Cow
Farrow to Feeder
D . P,o"It °'"`Cci
Po
Non -Dairy
Farrow to Finish
Layers
Beef Stocker
Gilts
Non -La ers
Beef Feeder
Boars
Pullets
Beef Brood Cow
t .
Turke s
Outer
er
jurkeyPoints
ther
Discharges and Stream Impacts
i . Is any discharge observed from any part of the operation?
❑ Yes
® No
T�
❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
❑ Yes
❑ No
M NA
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
❑ Yes
❑ No
e 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 DWQ)
❑ Yes
❑ No
[�p NA
❑ NE
2. is there evidence of a past discharge from any part of the operation`?
❑ Yes
No
❑ NA
❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters
❑ Yes
No
❑ NA
❑ NE
of the State other than from a discharge?
Page I of 3 21412011 Continued

Facili Number: 7,,j jDate of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes
a. If yes, is waste level into the structural freeboard?
Structure'1`tructure 2 Structure 3 Structure 4
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): c3�j
5. Are there any immediate threats to the integrity of any of the structures observed?
(i.e., large trees, severe erosion, seepage, etc.)
❑ Yes
Structure 5
No ❑ NA ❑ NE
❑ No �DNA ❑ NE
Structure 6
❑ Yes No ❑ NA ❑ NE
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 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 1p 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): S ZYwtZ U �.,.
I-
/-
13. Soil Type(s): 01/ z__ — ri i2k —
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
QLNo
❑ 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?
T
17. Does the facility lack adequate acreage for land application?
❑ Yes
No
❑ NA
❑ NE
18. is there a lack of properly operating waste application equipment?
❑ Yes
No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
® No
❑ NA
❑ NE
20_ Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
No
P
❑ NA
❑ NE
the appropriate box.
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other.
21. Does record keeping need improvement? if yes, check the appropriate box below. ❑ Yes No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V 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 21412011 Continued

Facili Number: - Date of ins ection:
24. Did the facility fail to calibrate waste application equipment as required by the permi . ❑ Yes " No ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes (D No ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail 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 ® No ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes No ❑ NA ❑ NE
and report mortality rates that were higher than normal? T
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 [�?No ❑ NA ❑ NE
❑ Yes 0 No ❑ NA ❑ NE
❑ Yes dpNo ❑ NA ❑ NE
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes �] No ❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes [$3 No ❑ NA ❑ NE
34_ Does the facility require a follow-up visit by the same agency? ❑ Yes No ❑ NA ❑ NE
Comments (refer to: question #)c Explain any YES' answers And/or any additional recommendations or any other comments �1�'
Use drawings of facili to better explain situations' use additional pages as necessary).4 =
g h P { P g
Reviewer/Inspector Name:
Phone:
Reviewer/Inspector Signature:
Page 3 of 3
Date: 7
2/412011

Type of Visit: 0 Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: 12KRoutine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: r /� Departure Time: County: Region:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact:
Onsite Representative:
Title:
Owner Email:
Phone:
Integrator:
Phone:
Certified Operator:%)gzCertification Number: (p n
Back-up Operator:
Certification Number:
Location of Farm: Latitude: Longitude:
wMAPENIP"M •
x Design' Current
Swine Capacity Pop.
Wet -Poultry
Design
C+apacity
Current
Pop.
Design Current
Cattle Capacity Pop.
Wean to Finish
Layer _ _
Dairy Cow
Wean to Feeder
on -Layer
Dairy Calf
Feeder to Finish
I) , Poul# ,.
Design
Ca aci.
Current
P,o ,
Dairy Heifer
Farrow to Wean
Farrow to Feeder
Dry Cow
Non -Dairy
Beef Stocker
Farrow to Finish
Layers
Gilts
Non -Layers
Pullets
Beef Feeder
Beef Brood Cow
Boars
Other
Turkeys
,Turkey Poults
Other
Other
6
Dischar es and Stream Impact DEQIDWR
1. Is any discharge observed from any part of the operation? No
Discharge originated at: ❑ Structure ❑ Application F lU
o 9 2 Other:
a Was the conveyance man-made?
W
b. Did the discharge reach waters of the StR WL I t 0 ICE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
❑ Yes No ❑ NA 0 NE
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes No
❑ Yes"I
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑NA ❑NE
Page 1 of 3 21412011 Continued

Facility Number: -2X7M jDate of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes X No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes PfNo ❑ NA ❑ NE
Struck I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier; U
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes P(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 VNo ❑ NA ❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes No ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes �No ❑ NA ❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes 9'No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes No ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, et .)
❑ 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): �Q t9
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
[Z] No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ 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 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
o
❑ NA
❑ NE
the appropriate box.
❑WUP El Checklists [:]Design [—]Maps ❑ Lease Agreements ❑Other.
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes �No
El Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V 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 4
No
[DNA ❑ NE
❑ Weather Code
❑ Sludge Survey
[]NA ❑NE
❑ NA ❑ NE
Page 2 of 3 21412011 Continued

!a
Facila -Number: 10 jDate of Inspection:
24. td ef fact failto calibrate waste application equipment as required by the permit? ❑ Yes CEfrNo ❑ NA ❑ NE
,
25. is the facility ou comp a with permit conditions related to sludge? If yes, check ❑Yes � NN
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 PTNo ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes 2TN—o ❑ NA ❑ NE
Other Issues
28. Did the facility fail to property 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 I /f No ❑ NA ❑ NE
❑ Yes YrNo ❑ NA ❑ NE
❑ Yes JE!J�No ❑ NA ❑ NE
[—]Yes {�No ❑ NA ❑ NE
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes 9-No ❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes
No ❑ NA ❑ NE
Reviewer/Inspector Name:
Reviewer/Inspector Signature
Page 3 of 3
Phone:
Date:
21412011

Type of Visit: QW-w ipliance inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: outine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: � Arrival Time: ! 4020 Departure Time: County:
Farm Name: r/ 4,0,f201 Z� / / L�_ Owner Email:
Owner Name: e Phone:
Mailing Address:
Physical Address:
Facility Contact: ///.tflr 1� Gzb/—Title: 1041 `P/Phone:
Onsite Representative: integrator: _22zes
101
Certified Operator: Certification Number:
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
Region: 5
Design Current Design Current
Design Current
Swine Ca a.co 'et Poult •
a aci P-
Wean to Finish Layer
Dairy Cow
Wean to Feeder
Non -Layer
Dairy Calf
Feeder to Finish
00
- -
Dairy Heifer
Farrow to Wean
esign.. Current
Dry Cow
Farrow to Feeder
D . P,oul . _ Ca achy Po P.
Non -Dairy
Farrow to Finish
Layers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
NJ
Boars
IPUIlets
Beef Brood Cow
Turkeys
Other
Turkey 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?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
❑ Yes �No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
[] No
❑ NA
❑ NE
d. Does the discharge bypass the waste management system? (If yes, notify DWQ) [:]Yes [:]No ❑ NA ❑ NE
2. Is there evidence of a past discharge from any part of the operation? [-]Yes C�j No ❑ NA ❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters [:]Yes f@ No ❑ NA ❑ NE
of the State other than from a discharge?
Page I of 3 21412011 Continued

[Facility Number: - / p Date of ins ection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes
a. If yes, is waste level into the structural freeboard? ❑ Yes
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5
Identifier:
[E-No ❑ NA ❑ NE
❑No DNA ❑NE
Structure 6
Spillway?:
Q
Designed Freeboard (in): f
Observed Freeboard (in): C3 t.{�
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
LA�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
C�_No
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health
or environmental
threat,
notify DWQ
7. Do any of the structures need maintenance or improvement?
❑ Yes
No
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
No
❑ NA
❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require
❑ Yes
Ig No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
[:]Yes
O,No
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. [:]Yes PSNo ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
Outside of Acceptable Crop Window ❑ Evidence of Wind Drill ❑ Application Outside of Approved Area
12. Crop Type(s): rkr e %l��s /' rf'L
13. Soil Type(s): 06-b 21 Z QVA 1W..15 / C'f—,(3 _
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes allo ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes [ No ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes E] No ❑ NA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
❑ Yes ® No ❑ NA ❑ NE
[:]Yes 0 No ❑ NA ❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes No ❑ NA ❑ NE
the appropriate box.
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes 2 No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes fD No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? 0 Yes JK No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑NA ONE
Page 2 of 3 21412011 Continued

Facie Number: - / Q 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 21 No ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge? [—]Yes ®, No ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes ER No ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Application Field ❑ Lagoon/storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
34. Does the facility require a follow-up visit by the same agency?
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
❑ Yes C, No ❑ NA ❑ NE
❑ Yes I& No ❑ NA ❑ NE
❑ Yes (RNo ❑ NA ❑ NE
❑ Yes Z[ No ❑ NA ❑ NE
❑ Yes FZ] No
❑ Yes 21 No
❑ Yes E]-No
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Phone: 2/0 x� - 33ao
Date: ��-/ 3 -1:9D r3
21412011

Type of Visit: 4P Compliance Inspection V Operation Review V Structure Evaluation V 'Technical Assistance
Reason for Visit: * Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: Departure Time: County: Region: F100
Farm Name: 3 'f., TOM- ��b/4t FL1'►M Owner Email:
Owner Name: ` [� N �� Phone:
Mailing Address:
Physical Address:
Facility Contact:
Onsite Representative: J H
Certified Operator:
Title:
Phone:
A.'z 4�."
Certification Number: 1 Ne lb
Integrator:
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
Design Current Design Current
Swine Capacity Pop. Wet,Poultry , Capacity Pap. Cattle
Design Cnrreat
Capacity Pop.
Wean to Finish
Layer
DairyCow
Wean to Feeder
Non -La er
DairyCalf
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Design Current
D . I',ouit , ., Ca aci Po
La ers
DairyHeifer
Cow
Non -Dairy
Beef Stocker
Beef Feeder
Beef Brood Cow
Gilts
Non -La ers
Boars
Pullets
Turke s
Turkey Poults
Other
Other
Other
Discharges and Stream gmaacts
1. Is any discharge observed from any part of the operation? ❑ Yes R No ❑ NA ❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made? ❑ Yes ❑ No 7T 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 the discharge bypass the waste management system? (If yes, notify DWQ) ❑ Yes ❑ No NA ❑ NE
2. Is there evidence of a past discharge from any part of the operation? ❑ Yes No ❑ NA ❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters ❑ Yes P No ❑ NA ❑ NE
of the State other than from a discharge?
Page I of 3 21412011 Continued

Faciii Number: - Q Date of Inspection: Z
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes [A No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No NA ❑ NE
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): .37�
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 K2)No ❑ NA ❑ NE
waste management or closure plan? T
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 9PNo ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes P
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 NMNo ❑ NA ❑ NE
maintenance or improvement'? TT
Waste ADDIiCatiOn
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes�r. No ❑ NA ❑ NE
maintenance or improvement? 7`
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes [�JNo ❑ 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): d 11
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes W o ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes FP No [DNA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes [!� No ❑ NA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
18_ Is there a lack of properly operating waste application equipment?
❑ Yes MNo ❑ NA ❑ NE
❑ Yes X No ❑ NA ❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available'? If yes, check ❑ Yes No ❑ NA ❑ NE
the appropriate box.
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. [:]Yes Cq No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis [] Waste Transfers
❑ Rainfall ❑ Stocking [:]Crop Yield ❑ 120 Minute Inspections []Monthly and I" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes] No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 21412011 Continued

Facility Number: Date of Inspection: 7 IMJI
7-
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
RS] No
❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check
❑ Yes
"r No
[3 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
JR] No
❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
No
❑ NA ❑ NE
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
No
❑ NA ❑ NE
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
❑ Yes
No
❑ NA ❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
TT
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below_
❑ Yes
�TNo
❑ NA ❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
No
❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
® No
❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
No
❑ NA ❑ NE
Comments (refer -If ttestio_w#): Explain any„YES anmiers;,nhggr:any addrtronai...recommendations or any other corninents.
Use drawings of facility to:better explain,situations.(use additional pages as necessary):
5 ILI �e_ :5 LIr vla� to I_ cll�_j Z-01 �11
Reviewerllnspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
� Phone:
Date: l ! q1 Z
21412011

type or visit. z}c.:ompttance inspection %j uperanon rceview V structure r,vaivation V iecnmcat Assistance
Reason for Visit: IStRoutine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: J i Arrival Time: ,QO Departure Time: T_ County:S(�Hj s n Region:
Farm Name^3D tkm UHAl Owner Email:
Owner Name: I �lt, (w �� � Phone:
Mailing Address:
Physical Address: _ I a s "k-e W k4* 4'l (WEP-
Facility Contact: , Men, id . Title: Phone:
Onsite Representative:y 11� i r f Integrator:
Certified Operator: C , PA w r. ky's, Certification Number:
Back-up Operator:
Location of Farm:
Latitude:
Certification Number:
Longitude:
!
DesignCarrent'
Design Current
Design
Current
_'
Swine
Capty'
Pop.
Wet Poultry
La er
Capacity
I op.
Cattle Capacity
p.
Wean to Finish
Dairy Cow
Wean to Feeder
Layer
Dairy Calf
Feeder to Finish
$
+
t
Dai Heifer
Farrow to Wean
_:
Design
Current
Dry Cow
Farrow to Feeder
D . IPoul
Ca�'acity
_ _Po
Non -Dairy
Farrow to Finish
Layers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
1
Turkeys
OOther
-Turkey Poults
OtherI
10ther
.
..widhliY�"u -Y+15YL�}n4iF�4
�F. .
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
[:]Yes §j No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
d. Does the discharge bypass the waste management system? (if yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
❑ Yes ❑ No
❑ Yes & No
[:]Yes JR[ No
❑NA ❑NE
❑NA ❑NE
❑NA ❑NE
Page 1 of 3 21412011 Continued

Facility Number: -,)- - a j Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes P No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in): �
Observed Freeboard (in): *3Jr
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes N-el 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
[5� 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 env' onmental
threat,
notify DWQ
7. Do any of the structures need maintenance or improvement?
1'es
WNo
❑ 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
P No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
IR No
❑ NA
❑ NE
maintenance or improvement?
11. 1s there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes RI 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 � j ❑ Evidence of Wind Drift _❑ Application Outside of Approved Area
12. Crop TYpe(s): CnA-61 bo,% Ld n 4a v �.smll amin ownp -&
13. Soil Type(s):I
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes 12 No ❑ NA 0 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?
IT Does the facility lack adequate acreage for land application?
18_ Is there a lack of properly operating waste application equipment?
[3 Yes E] No ❑ NA ❑ NE
❑ Yes [S No ❑ NA ❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes N No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes f�a No ❑ NA ❑ NE
the appropriate box.
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements []Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. �? Yes ❑ No
R Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V 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 21412011 Continued

FaciRt Number: - alo jDate of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes N No ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes W 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
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 ReviewerAnspector fail to discuss review/inspection with an on -site representative?
34. Does the facility require a follow-up visit by the same agency?
T F`16� �.Ybf k a, bae- S& Q') )aj �iIPE � D�J01 S !11
IT New -(Ads l) -(�'M -v joal cow-,
)s, S 1t,dje fxIsOA M f Doty
IRP'.-U a�Prxllalt��r�.rPaD-01,
Ilv���ma,��u cL f mala��a re(odl.
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
ao Schn�eiA-
❑ Yes
10 No
❑ NA
❑ NE
❑ Yes
❑ No
CR NA
❑ NE
❑Yes
®No
❑NA
❑NE
❑ Yes CR No ❑ NA ❑ NE
❑ Yes 151 No ❑ NA ❑ NE
❑ Yes ;H No ❑ NA ❑ NE
❑ Yes CR No
❑ Yes fg No
❑ Yes V No
❑NA ❑NE
❑ NA ❑ NE
❑ NA ❑ NE
Co, 14e- ha, fvrmL lci
Phone:
Date: 1 (Q DOA
21412011

Facility No. Farm Name 3 V Date
Permit COC OIC_ NPDES (Rainbreaker PLAT Annual Cert)
J
FB
Drops
Lagoon
1
2
3
4
5
6
7
Spillway
Design freeboard
Observed freeboard in
Sludge Survey Date
Sludge Depth ft
Liquid Trt. Zone ft
Ratio Sludge to Treatment Volume
Calibrati n Date
1$!
2
3
4
5
6
7
8-
Design Flow
1I4
Actual Flow
-
Design Width
3
Actual Width
Soil Test Date IS
SiWettable Acres L/ RAIN GAUGE
pH Fields WUP ✓ Dead box or incinerator
Lime Needed Weekly Freeboard Mortality Records
Lime Applied ���_ 1 in Inspections
Cu-I \./Zn-I �_ 120 min Insp.
Needs P Weather Codes
Cron Yield Transfer Sheets
000
•
�'
�-
Pull/Field Soil Crop Acres PAN Window Max Rate Max Amt
2 U0 Cb May "!is I - 6 r r�
C -
Verify PHONE NUMB R and affiliations
Date last WUP ^ FRO jI 9 jp Date last WUP at farm Ap . Hardware
sdT�Q
FRO or Farm Recotds 1 4
Lagoon # wb m �0D9v/1
Top Dike
Stop Pump
Start Pump
Conversion- Cu-I 3000= 108 Iblac; Zn-I 3000= 213 Iblac

i
Type of visit: o;outine
nce Inspection Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: %%� Arrival Time.-�Departure Time: ;/ County: Region:
Farm Name: Fr1� �i Carte Owner Email:
Owner Name:Phone:
Mailing Address:
Physical Address:
Facility Contact:
/2 Title:
Onsite Representative:
Certified Operator: G� f
Integrator
Phone:
Certification Number:
Back-up Operator: Certification Number:
Location of Farm:
Latitude: Longitude:
FDeli n Curren µ
z a g Destgn' Current Design Current
Swine � �Capac'it I 'Pop. Wet Poultry @apacity Pop. !I C►apacity Pop.
14
Wean to Finish La er Da Cow
Wean to Feeder on -Layer Da' Calf
Feeder to Finish
Dairy Heifer
Farrow to Wean
Design Cnrrent Dry Cow
D , _Paul Ca aci P.o Non -Dairy
Farrow to Feeder
Farrow to Finish
Layers Beef Stocker
Gilts
Non -Layers Beef Feeder
Boars
Pullets
I 113eef Brood Cow
Turkeys
Other
Turkey Poults
Other
Other
Discharges and Stream Impacts
1, Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Appiication Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
❑Yes §gNo ❑NA ❑NE
❑ Yes ❑ No ❑ NA ❑ NE
❑Yes No ❑NA ❑NE
d. Does the discharge bypass the waste management system? (If yes, notify DWQ) ❑ Yes ❑ No ❑ NA ❑ NE
2. Is there evidence of a past discharge from any part of the operation? ❑ Yes ® No ❑ NA ❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters ❑ Yes Ig No ❑ NA ❑ NE
of the State other than from a discharge?
Page 1 of 3 21412011 Continued

Facili Number: - e Ds ection: f O
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes [S 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: 1rx7 1ci11,
Spillway?:
Designed Freeboard (in): / 17
Observed Freeboard (in): 35—
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes [gNo ❑ 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 [j3.No
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat,
notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes �[ No
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit? [2 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 [Z No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes Co 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): vrvt, z r
i
13. Soil Type(s): ) ofi4k/k-
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes f@ 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 [g No ❑ NA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
❑ Yes ® No ❑ NA ❑ NE
® Yes ❑ No ❑ NA ❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes �q No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes 0 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 fo No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V 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 21412011 Continued

Facili 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 � 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
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
[2 No
❑ NA
❑ NE
❑ Yes
[allo
❑ NA
❑ NE
❑ Yes
[a No
❑ NA
❑ NE
[:]Yes 0 No ❑ NA ❑ NE
❑ Yes C,No ❑ NA ❑ NE
❑ Yes ® No ❑ NA ❑ NE
[:]Yes �&No
❑ Yes D? No
aYes ❑ No
❑ NA ❑ NE
❑NA ❑NE
❑ NA ❑ NE
Comments (refer to question ft Explain any YES answers and/or any additional recommendations or any other comments.
Use drawings of facility to better explain situations (use additional pales as necessarv).
de, 0P7,_-,e1*u
�GUC.�G!jCCr� 1 %ud
t�/'
/r_N - `7�� a
Py
/,n �v; r[ roc► vim. Q- � �� c 17, 5 - Fos- 'Ekcni;,�,`v,
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: CUo—j/- 7.33ao
Date:
21412011

Facility Nn>E i
Type of Visit ?$Compliance Inspection O Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit P�Routlne O Complaint O Follow up O Referral O Emergency O Outer ❑ Denied Access
Date of Visit: Arrival Time: Ltd L:� Departure Time: County,
Farm Fame: Ph1h �V *_ (� Owner Entail:
Owner Name: V,�U FC Phone:
Mailing Address:
Physical Address: J ID 26 KQihn W V'a_ wove
�1
Facility Contact: ` Qv Title: O WM1i^ , Phone No:
Onsite+Representative: 4 "Af,Integrator:
r
Certified Operator: I Operator Certification Number:
Back-up Operator: Back-up Certification Number:
Location of Farm:
Swine
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Other
❑ Other
Region: FM
Latitude: = o = 1 ❑ n Longitude: ❑ 0 = ' = a
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer
j ❑ Non -Layer
Dry Poultry
Pullets
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
Design Current
Cattle Capacity Population
❑ Dairy Cow
Type of Visit ?$Compliance Inspection O Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit P�Routlne O Complaint O Follow up O Referral O Emergency O Outer ❑ Denied Access
Date of Visit: Arrival Time: Ltd L:� Departure Time: County,
Farm Fame: Ph1h �V *_ (� Owner Entail:
Owner Name: V,�U FC Phone:
Mailing Address:
Physical Address: J ID 26 KQihn W V'a_ wove
�1
Facility Contact: ` Qv Title: O WM1i^ , Phone No:
Onsite+Representative: 4 "Af,Integrator:
r
Certified Operator: I Operator Certification Number:
Back-up Operator: Back-up Certification Number:
Location of Farm:
Swine
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Other
❑ Other
Region: FM
Latitude: = o = 1 ❑ n Longitude: ❑ 0 = ' = a
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer
j ❑ Non -Layer
Dry Poultry
Pullets
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
❑ Dairy Calf
❑ Dairy Heifer
❑Dry Cow
❑ Non -Dairy
❑ Beef Stocker
❑ Beef Feeder
❑ Beef Brood Co
Number of Structures:
b. Did the discharge reach waters of the State? (if ves, 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 ;3 No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
19 No
❑ NA
❑ NE
❑ Yes
5irNo
❑ NA
❑ NE
12129104 Continued

10 ;V
Facility Number: a —
Date of Inspection
Waste Collection & Treatment
4. is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
�2 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): 9 �L' [Il �� ok dlw�_
Ij
Observed Freeboard (in): 3S
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
CRNO
❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
❑ Yes
O'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
P No
❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit?
❑ Yes
5allo
❑ 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
JRNo
❑ NA ❑ NE
maintenance or improvement'?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
E'No
❑ NA ❑ NE
maintenance/improvement'?
11. Is there evidence of incorrect application? If yes, check the appropriate box below.
❑ Yes
tR-No
❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 Ibs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge
into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside
of Area
12. Crop type(s) Q661M I L5f m vd at . f'f{,l y .`� �� Ana I I /1 /0 i;n e)vA-sFk4f
13.
Soil type(s) 66 I k J J
14.
Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
UrNo
❑ NA
❑ NE
15.
Does the receiving crop and/or land application site need improvement?
❑ Yes
I�FNo
❑ NA
❑ NE
16.
Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
❑ Yes
R No
❑ NA
❑ NE
17.
Does the facility lack adequate acreage for land application?
❑ Yes
RNo
❑ NA
❑ NE
18.
Is there a lack of properly operating waste application equipment?
❑ Yes
RNo
❑ NA
❑ NE
Reviewer/inspector Name , �+ f'j" r ' i K � Phone�gM Wj 33GbJe 3333
—y
Reviewer/Inspector Signature: Jr/jia Date: (� �,aO1 D
1:
12128104 Continued

�1r-ec m dv
dad aEn
` Facility Number: — Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes [@ No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes JNo ❑ NA ❑ NE
the appropriate box. ❑ VFUp ❑ Checklists ❑ Desig
n ❑ maps
p ❑ Other
21. Does record keeping need improvement? If yes, check the appropriate box below. Yes ❑ No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rain Inspections ❑ Weather Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
JZNo
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
❑ No
RNA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
YNo
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
P No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
2No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
❑ No
*ENA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
tR No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
IgNo
❑ 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
JRNo
❑ 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
t5 No
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
ErNo
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
Wo
❑ NA
❑ NE
A`dditional�,Comment`s�;'andl�ar'�Draw€ngs ;
4 4-. o)d n2 tv woyo
farm coly`4 _ lY , So I Id set- +© ripe/ dt1r, +1 b's ampe-.
6W-�°� a� c r a� rd- r�erord
tdrqI of grow,, 1
3+� D 11t Vej
121(2&04

ago
Fatuity No.'B�:�� Farm Name V/", TV L1/(Q _ Date Ito
Permit COC OIC, NPDES (Rainbreaker PLAT Annual Cert )
RUM �
Lagoon
1
2
3
4
5
6
7
Spillway
Design freeboard
Observed freeboard in
Sludge Survey Date
Sludge Depth ft
Liquid Trt. Zone ft
Ratio Sludge to Treatment Volume
C+Z�rTi,;' l7� 7i�+TilT['ll
Calibration Date
1
2
3
4
5
6
7
8
Design Flow
Actual Flow
Design Width
Actual Width
Soil Test Date Wettable Acres RAIN GAUGE
pH Fields WUP wV ��7 1{Dead box or incinerator
Lime Needed Weekly Freeboard Mortality Records
Lime Applied 1 in Inspections
Cu-I Zn-I 120 min Insp.
Needs 15Weather Codes
Crop Yield ✓ Transfer Sheets
Waste Analysis Date
- 60 Da
+ 60 Da
N Amt Ib/1000 Gal
H
.
..
..
1111i�r'.
L�fl��'Y
�r�Ulr�
I♦�i�r[��t��e�
MW
���_
Emil I
Verify PHONE NUMBERS and affiliations
Date last WUP FRO `$-aq-QI Date last WUP at farm
FRO or Farm Records
Lagoon #
Top Dike
Stop Pump L) D
Start Pump q.T, 3
Conversion- Cu-I 3000= 108 Ib/ac-, Zn-I 3000= 213 Ib/ac
App. Hardware
1
/1

0 Division of Water Quality
=ilumber $Z Z lD 0 Division of Soil and Water Conservation
- — — -- 1'J Other Agency
Type of Visit 0 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. %.34 ,H Departure Time: County: ��gr:%aSo s/.. Region: Flo
Farm Name: 3 D �+�'h'1 Owner Email:
Owner Name: %AI Phone:
Mailing Address:
Physical Address:
Facility Contact: 49111" Da u c Li 1s-1. Title: Phone No:
Onsite Representative: �e_
MA" C Integrator: P,�,wi,u.K _ boy rrr�S
Certified Operator:
Back-up Operator:
Operator Certification Number:
Back-up Certification Number:
Location of Farm: Latitude: = = f ❑ !i Longitude: ❑ ° = g 0 u
Design Current
DesignNO ' Current
Design Current
Swine
Capacity Population
Wet Poultry
Capty Population
Cattle
Capacity Population
❑ Wean to Finish
❑ Layer
❑ Dairy Cow
Wean to Feeder
306-0
❑ Non -Layer
❑ Dairy Calf
❑ Dai Heifer
Feeder to Finish
Z
❑ Farrow to Wean
�Pnlwy
rn -:
❑ D Cow
❑ Farrow to Feeder
'➢
Farrow to Finish
La ers❑Non-Dai❑
Non -La ersPullets
r
❑ Beef Stocker
❑Beef Feeder
❑Beef Brood Co
❑ Gilts
❑ Boars
Other
El Turkeys
El
`` {
Turkey Pouits
❑ Other
Numlier�of�Structures:
❑
❑ Other`
DischariYes & Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
1;9 No
❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
❑ Yes
qNo
❑ NA
❑ NE
b. Did the discharge reach waters of the State? (I f yes, notify llWQ)
El Yes
[,kNo
❑ NA
El 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
7No
❑ NA
❑ NE
1 Is there evidence of a past discharge from any part of the operation?
❑ Yes
[?;No
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
[�ONo
❑ NA
❑ NE
other than from a discharge?
Page I of 3
12128104
Continued

Facility Number: Z Z/D Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes O No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes � No [I NA ❑ NE
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?.
Designed Freeboard (in):
Observed Freeboard (in): 3$
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes
C�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
PNo
❑ 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
1� No
❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes
C9 No
❑ NA ❑ NE
(Not applicable to roofed pits, dry stacks and/or wet stacks)
9_ Does any part of the waste management system other than the waste structures require ❑ Yes
VNo
❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes
[;5No
❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes
[XNo
❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 Ibs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into
Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
1
12. Crop type(s) r u '>4 A/ (j hfii✓ (D Je.V5 < 1-aL/ )
13. Soil type(s) //p 14
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes
❑ No
❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement'? ❑ Yes
❑ No
❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ? ❑ Yes
❑ No ❑ NA ❑ NE
17. Does the facility lack adequate acreage for land application? ❑ Yes
❑ No
❑ NA ❑ NE
18. Is there a lack of properly operating waste application equipment? ❑ Yes
❑ No
❑ NA ❑ NE
Comments (refer to question #):. Explain any YES answers and/or any recommendations or any other comments r
Use drawings of facility to better explain situations. (use additional pages. as necessary) :.
Reviewer/inspectorName € �� {� p,,,`[s Phone: W0 fW,.3_300
Reviewerllnspector Signature: d,...� Date: $— ZZ —2-&0 Co
Page 2 of 3 12128104 Continued

Facility Number: $Z —LO Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes UNo ❑ NA ❑ NE
20. Does the facility fail to have all components of the CA WMP readily available? If yes, check ❑ Yes [g No ❑ NA ❑ NE
the appropriate box.
❑ WUP El Checklists El Design El Maps ❑Other
21. Does record keeping need improvement? if yes, check the appropriate box below. ❑ Yes [�&0 ❑ 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 ()?No ❑ 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
[XNo
❑ NA
❑ NE
25. Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
VNo
❑ NA
❑ NE
26. Did the facility fail to have an actively certified operator in charge?
❑ Yes
DfNo
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
59 No
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
0 No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
,W 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
Pff 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? (icl discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
R No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
[RNo
❑ NA
❑ NE
Comments and/or Drawings:
Page 3 of 3 12128104

3
8.� H A /a
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: ' p6a� Departure Time: County: -�2^•, Region: F?O
Farm Name: 30 -ra#/6 Owner Email:
Owner Name: �� �u a �f� Phone: C1/d-
Mailing Address: J 9Go /Poa�naf'1. R�.i e%'�><e� NC 2
Physical Address:
Facility Contact: Dn,eti A :; ,—_/ Title:
Onsite Representative: _ ae 4 N, �.ae
Certified Operator: 64, IP. Da V
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
Phone No:
Integrator
Operator Certification Number: 64
Back-up Certification Number:
Latitude: = OF—]' ❑ « Longitude: o = u
Design Current , Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer
1 JLJNon-La et
Other °
❑ Other i
Dry Poultry,
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ Turkey Pouets
❑ 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
❑ Dairy Calf
❑ Dairy Heifer
❑ Dry Cow
❑ Non -Dairy
❑ Beef Stocket
❑ Beef Feeder
❑ Beef Brood Co
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 Slate
other than from a discharge?
❑ Yes 2'flo ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑Yes
❑No
El NA
El NE
❑ NA
❑ NE
❑ Yes
❑lNo
❑ Yes
oo
❑ NA
El NE
❑ Yes
,[-,��
Leo
❑ NA
❑ NE
12128104 Continued

82- 2to
Facility Number: Rq—
16M s Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
0-Ko
❑ 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: _. i
Spillway?: he
Designed Freeboard (in):�
Observed Freeboard (in):��''"
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
D-Tgo
❑ NA
❑ NE
(ic/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
❑ Yes
❑No
❑ NA
❑ NE
through a waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or
environmental threat,
notify DWQ
7. Do any of the structures need maintenance or improvement?
❑ Yes
2No
❑ NA
❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit?
❑ Yes
3No
❑ 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
QNO
❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
2No
❑ 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 l0 lbs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acce table Crop Window El Evidence of Wind Drift El Application Outside of
�Q
Area
12. Crop type(s) Le7�a+'1 sr%fa�� ��i^ Ag^_ &d0� urns s JV
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
2 No
❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
�o
❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination%❑
Yes
❑ No
❑ NA [-NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
❑ No
❑ NA a1ME
18. is there a lack of properly operating waste application equipment?
❑ Yes
D-N—o
❑ NA ❑ NE
Tte o(es:gnra� f-rea4moro s may'` �[cvlr•�.�(tli,`s u„ �i A,, N.'e.wo�o( ..r►./ 4c s44
4G wevU I^e+ri.„ kA,'5 w: H Mr
Reviewer/Inspector Name Q � Phone: I/O — y g -15-It !,, 7 3 v
Reviewer/Inspector Signature: Date: 3 3"j- a f-
l2/28/04 Continued

'g.7• Rio 10*0
Facility Number: f,g Date of inspection
Re wired Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes 9j< ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes EKo ❑ NA ❑ NE
the appropirate box. ❑ Vl�❑ Che sts ❑ Upeign ❑ M�1] Oef
21. Does record keeping need improvement? if yes, check the approgrit�
❑ �duel box below. 0-yeses ❑ No El NA El NE
--dree mzrd El9 S ❑ Soil�ra4y,3is' ❑ ❑
El �irrfath- �rtg 2 rop Yield ❑ 1 �onthly and 1 " Rain Inspections ❑
22. Did the facility fail to install and maintain a rain gauge?
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
24. Did the facility fail to calibrate waste application equipment as required by the permit?
25. Did the facility fail to conduct a sludge survey as required by the permit?
26. Did the facility fail to have an actively certified operator in charge?
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
and report the mortality rates that were higher than normal?
30. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately
31. Did the facility fail to notify the regional office of emergency situations as required by
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
33. Does facility require a follow-up visit by same agency?
Additional Comments and/or Drawings:
3, �°%asc %�pCr.% ra •y �.�/r�r- r V^G ��'yy br�� ��e� � 1 6►UKe�
c11,el/ y Lae
21ves
❑ No
❑ NA
❑ NE
❑ Yes
[-Iqo
❑ NA
❑ NE
❑ Yes
['Vo
❑ NA
❑ NE
El Yes
ONo
El NA
[I NE
❑ Yes
[-No
❑ NA
❑ NE
❑ Yes
ONo
❑ NA
❑ NE
❑ Yes [?No ❑ NA ❑ NE
❑ Yes [�To ❑ NA ❑ NE
❑ Yes [rNo ❑ NA ❑ NE
❑ Yes ['No ❑ NA ❑ NE
❑ Yes ❑'No ❑ NA ❑ NE
❑ Yes ❑'No ❑ NA ❑ NE
P/rpse % or w1J/
i rdr .07 ihl
% rc�►'n ,nSrtc".vnS� �Gv ew�r�
12128104

Type of Visit °u Compliance Inspection O Operation Review O Lagoon Evaluation
Q Reason for Visit Routine O Complaint O Follow up O Emergency Notification O Other ❑ Denied Access
Facility Number alo Date of Visit: Time: lo: Dd
O Not Operational O Below Threshold
diermitted E(Certified © Conditionally Certified [3 Registered pate Last Operated or Above Threshold: ...... _. ..
Farm Name: ..i fly ..?°'a- ACounty: ...... .__ .......... __,. ... .
Owner Name: h_ I
----•-�-�-�`"�-_.•--�—`�'t`��.`�.� ............._.......... Phone No: 56 7 (. I iLI-
lltailing Address: •_ 1140 _ _- )?MAo ki �, l �I •vtiv►� � N C o� 8 3 a g
Facility Contact: ........ F, .. ..Re.�'�`� Title:.. .... ._. _. Phone No:
Onsite Representative...__,-- 1�1� f�iN �e.,� ic—n.E Integrator _. ��+;�*„^ 5`tw'! s�r�----___.—_
- '�._ -
Certified Operator:..- +� ...�. �a'"3r Operator Certification Number:
Location of Farm:
Mr'S`w_ ine BlIp"Oultry ❑ Cattle ❑ Horse Latitude • ` " Longitude • 6 «
Swine
113es�gn Currentt m Design Current
Ca _ci Po ulatioa'Poul P; ci bu` _Cattle
Po alatx
an to Feeder
m,
Layer
ffFeederto Finish
a,g90
ag
Fo Non -Layer
E�1�
Farrow to Wean-'
Other
Farrow to Feeder
Farrow to Finish
- s Total D
e
esygn " Curr�t s
_ - G
3k�D
Nuuibes of Lagoons
P
- :Hnlriina Pnnrlc`1 Giliri;Ti•anc c � _- -. :." �'�"'�'
Discharges & Stream Iinaact5
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made?
b. If discharge is observed, did it reach Water of the State? (If yes, notify DWQ)
c. If discharge is observed, what is the estimated flow in gal/min?
El Yes IN'o
❑ Yes ❑ No
❑ Yes ❑ No
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 01�0
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes ["No
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway [:]Yes Ef'No
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: .............._.....- - - _............................__ .
Freeboard (inches):
12112103 Continued

Facility Number: — gt0 Date of Inspection ! o
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, ❑ Yes [�No
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or ❑ Yes GKO
closure plan?
(If any of questions 4-6 was answered yes, and the situation poses an
immediate public health or environmental threat, notify DWQ)
7. Do any of the structures need maintenance/improvement? ❑ Yes [>(No
8. Does any part of the waste management system other than waste structures require maintenancerimprovement? ❑ Yes Ed'No
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level ❑ Yes [2fNo
elevation markings?
Waste Ammlication
10. Are there any buffers that need maintenanceltmprovement? ❑ Yes C3'No
11. Is there evidence of over application? If yes, check the appropriate box below. ❑ Yes [jrNo
❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload ❑ Frozen Ground ❑ Copper and/or Zinc
12. Crop type Cr.. y�, S.�►a J ► fiLk; " (,ntc)
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)? ❑ Yes [�Vo
14. a) Does the facility lack adequate acreage for land application? ❑ Yes [ErNo
b) Does the facility need a wettable acre determination? ❑ Yes 03"No
c) This facility is pended for a wettable acre determination? ❑ Yes E3No
15. Does the receiving crop need improvement? ❑ Yes ["No
16. Is there a lack of adequate waste application equipment? ❑ Yes B"No
Odor Issues
17. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below ❑ Yes EB/No
liquid level of lagoon or storage pond with no agitation?
18. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes m No
I9. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt, ❑ Yes 03"No
roads, building structure, and/or public property)
20. At the time of the inspection did the facility pose an odor or air quality concern? If yes, contact a regional ❑ Yes [dNo
Air Quality representative immediately.
Reviewer/Inspector Name -- I _ " Reviewer/Inspector Signature: Date: Wljo ��
12112103 -4111- Continued

Facility Number: qg- a D Date of Inspection
Required Records & Documents
21. Fail to have Certificate of Coverage & General Permit or other Permit readily available? ❑ Yes [21 No
22. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.) ❑ Yes [Ao
23. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes B"No
❑ Waste Application ❑ Freeboard ❑ Waste Analysis ❑ Soil Sampling
24. Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
02 No
25. Did the facility fail to have a actively certified operator in charge?
❑ Yes
[?/No
26. Fail to notify regional DWQ of emergency situations as required by General Permit?
❑ Yes
&No
(iel discharge, freeboard problems, over application)
27_ Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes
53 No
28. Does facility require a follow-up visit by same agency?
❑ Yes
[2/No
29. Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
GrNo
NPDES Permitted )Facilities
30. Is the facility covered under a NPDES Permit? (If no, skip questions 31-35)
E(Yes
❑ No
31. If selected, did the facility fail to instaA and maintain rainbreakers on irrigation equipment?
❑ Yes
M"N' o
32. Did the facility fail to install and maintain a rain gauge?
❑ Yes
G No
33. Did the facility fail to conduct an annual sludge survey?
3111 es
❑ No
34. Did the facility fail to calibrate waste application equipment?
Yes
❑ No
35, Does record keeping for NPDES required forms need improvement? If yes, check the appropriate box below.
❑ Yes
To
❑ Stocking Form ❑ Crop Yield Form ❑ Rainfall ❑ Inspection After I" Rain
12112103

Site Requires Immediate Attention:
Facility No.
DIVISION OF ENVIRONMENTAL MANAGEMENT
ANIMAL FEEDLOT OPERATIONS SITE VISITATION RECORD
DATE: a �// _ 1995
Time: r r
Farm Narnc/Owner: -T�3 M 110 Ek\\4 Ra Dc�v erg
Mailing Address:
County:
1gwo P,ocrArivQ. •Ptd
h
1irVon nC a 83a $
Integrator. Phone::S551t-oaia
On Site Representative: Phone: 5 oa l S
Physical Address/Location-
f Taw
Type of Operation: Swine 'F;''�. Poultry �attic
Design Capacity: ZSVO Number of Animals on Sim: -`;i"e
DEINI Certification Number: ACE DEM Certification Number. ACNEW-
Latitude: d3S ' 2, ,4,9" Longitude:ly A ' 2!(-' If J. "
Circle Yes or No
Does the Animal Waste Lagoon have sufficient freeboard of 1 Foot + 25 year 24 hour storm event
(approximately 1 Foot + 7 inches) Xe or No Actual Freeboard: �, -Ft. Inches
Was any seepage observed from the 1 oon(s)? Yes o No Was any erosion observed? Yes -or N�
Is adequate land available for spray. Ye or No Is the cover crop adequate? �ar No
A
Crop(s) being utilized: C
Does the facility nicet SCS minimum setback criteria? 200 Feet from Dwellings? Ye or No
100 Feet from Wells? �,or No
Is the animal waste stockpiled within 100 Feet of USGS Blue Line Stream? Yes or N
Is animal waste land applied or spray irrigated within 25 Feet of a USGS Map Blue Line? Yes or
Is animal waste discharged into waters of the state by man-made ditch, flushing system, or other
similar man-made devices? Yes 049 If Yes, Please Explain.
Does the facility maintain adequate waste management records (volumes of manure, land applied.
spray irrigated on specific acreage with cover crop)? 'Yes or No
Additional Comments: .
Inspector Name Signature _ ---
cc: Facility Assessment Unit Use Anachments if Needed.

REGISTfATION FORM FOR ANIMAL FEEDLOT OPEP.ATIONS
Department of Environment, Health and Natural Resources
Division of Environmental Management _.
Water Quality Section
a ` the animal waste manacement system for your feedlot operation
is
designed to serve more than. or
equal to 100 head
of cattle,
75
horses, 250 swine, 1,000 sheep,
or 30,000 birds that
are served
by
a liquid waste system, then this
form must be filled
out and mailed
by December 31, 1993 pursuant to
15A NCAC 2H-0217 (c)
in order to
be
deemed permitted by DEM. Please print clearly_
Farm Name: -3 D u„r 7 D I- 1
eta i ling Address:
County:
Owner (s) Name: }� s�y R4v✓u��'rY
Manager (s) Name:.
Lessee Name:
=arm Locacion (Be as specific as possible: road names, direction,
milepost, etc-) : O S ,,t
Latitude/Longitude if known: W- U
Design capacity of animal waste manag
of confined animal (s)) : ��aks
Average animal population on the farm (Number and type of animal (s)
raised) --., . a$�O -- FX'I'r,
Year Production Began :_Lj_q_� ASCS Tract 7
fNo .: `�1 —
L Type of Waste Management System Used: r
Acres Available for Land Appligation pf, Waste: /..� r•t..s r
Owner (s) Signature (s) : 1 DATE:
DATE:

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