820348_INSPECTIONS_20171231

NORTH CAROLINA
Department of Environmental Quai

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 0 Denied Access
Date of Visit:
Arrival Time:
Departure Time: County:,�$h Region:
Farm Name: '��
;7
Owner Email:
Owner Name: r-[
5
Phone:
_
Mailing Address:
Physical Address:
Facility Contact: c.� Li hu S !. a Z Title:
14
Onsite Representative: rr
Certified Operator: JOLn't_5 U)Q46
Phone:
Integrator: res 5
P
Certification Number:) (i33f�
Back-up Operator: Certification Number:
Location of Farm: Latitude: Longitude:
Design Current
Design Current
Design Current
Swipe&Z
MapicePo P=
Wet Poalt .' Ga�ac" Pv'
ry p d?' P•
Cattle
Ca ach
p h' p•
Wean to Finish
Dairy Cow
I ILayer
Wean to Feeder
Non -La er
I
Dairy Calf
Feeder to Finish
"'' ' `
Dairy Heifer
Farrow to Wean
Design` Current
D Cow
Farrow to Feeder
D . 1?oul Caaci P.o # '
Non -Dairy
Farrow to Finish
Layers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turkeys
=
Other
Turkey PoultsF
utter
Other
Discha es and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify 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 �1 No ❑ NA ❑ NE
❑ Yes ❑ No ® NA ❑ NE
❑Yes [:]No CgNA ❑NE
[—]Yes ❑ No NA ❑ NE
❑ Yes No ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
Page I of 3 21412015 Continued

Facility Number: Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes o ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? DYes rNo NA ❑ NE
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes "No ❑ NA ❑ NE
(i_e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a ❑ Yes ® No ❑ NA ❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify 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 j}1 No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, 7_n, etc)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Win rift ❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s): Ca `
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?
18. Is there a lack of properly operating waste application equipment?
❑ Yes
[�TNo
❑ NA
❑ NE
[:]Yes
P No
❑ NA
❑ NE
Reuuired 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 P N
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking El Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1 " Rainfall inspections
22. Did the facility fail to install and maintain a rain gauge? El Yes No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes N
o ❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
o ❑ 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 [ 3M ❑ 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. ep
❑ 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 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 CA WMP?
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?
Reviewer/Inspector Name
ReviewerAnspector Signature:
Page 3 of 3
MIA
❑ Yes F No ❑ NA ❑ NE
❑ Yes �] No ❑ NA ❑ NE
❑ Yes F No ❑ NA ❑ NE
❑ Yes © No ❑ NA ❑ NE
❑ Yes No
❑ Yes ( No
❑ Yes K No
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Phone: (P-q 33~33ov
Date:
21412015

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 0 Denied Access
Date of Visit: Arrival Time: Departure Time: ounty:
Farm Name: / Owner Email:
Owner Name:Phone:
Mailing Address:
Physical Address:
Facility Contact: Ja"s
Onsite Representative:
Certified Operator: &Lf�k eo'
Back-up Operator:
Location of Farm:
Title:
Latitude:
Region:
Phone:
Integrator:
Certification Number: % 3S
Certification Number:
Longitude:
n Currents
-
Design�Current
Design Current
Swine ImosgLugmaluty
Pop" v " r *
n WetPoultry
Capac ty1Pop.
0Wr
Cable Capacity Pop.
. r
€
Wean to Finish
Layer
DairyCow
Wean to Feeder
Feeder to Finish
Non -Layer
l :"
s d
Dai Calf
DairyHeifer
Farrow to Wean
Farrow to Feeder
D : P.oult ,
Design Cdrrent
Ca acPo
D Cow
Non -Dairy
Farrow to Finish
Gilts
Layers
Non -Layers
Beef Stocker
Beef Feeder
Boars
I
r � ,..
jPullets
Turke s
Beef Brood Cow
Other
:' _
TurkeyPuuets
Other
Other
-.
Discharp-es and Stream Impacts
1. is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
❑ Yes P No ❑ NA ❑ NE
❑ Yes [—]No NA ❑ NE
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 L�j 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

FaciliNumber: jDate 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 KNo NA ❑ NE
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: -
Spillway?:
Designed Freeboard (in):
1�
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes No ❑ NA ❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a ❑ Yes No ❑ NA ❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes BANO ❑ 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 ADDlication
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 D 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 0 Evidencesf Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s):
lb
ll
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
No
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
No
[] NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
No
❑ NA
❑ NE
the appropriate box.
❑WUP ❑Checklists El 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 Tryfiers
❑ 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 N
o
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑NA ❑NE
❑ NA ❑ NE
Page 2 of 3 21412011 Continued

IFaciUty Number: - Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
y�
No ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check
❑ Yes
No ❑ NA ❑ NE
47
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
1� 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
PVM
4j No NA ❑ NE
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
❑ Yes
No ❑ NA ❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Yes
No ❑ NA ❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
No ❑ NA ❑ NE
33. Did the Reviewer/inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
No C] NA ❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
P No ❑ NA ❑ NE
Comments (refer to question #): Explain any YES: answers -and/or any additional recommendations or2any'�otlser commepts.
use:driwrng-s. of facility to better explain situations (use additional paces as necessary)..;.
Reviewer/inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: g�0
Date:
21412011

iype or visa: u t ompttance inspection v Uperation xceview u btructure tvaeuanon u t ecnnicm Assistance I
Reason for Visit: O Routine O Complaint O Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit: 3 t Arrival Time: (J;�ft Departure Time: r .'-County: ;�V Region: �w
Farm Name: `�1 V ' Owner Email:
Owner Name: Vmr"45t� ., ti..`s Phone:
Mailing Address:
Physical Address:
Facility Contact: �C Vyw_s Li b Title: Phone:
Onsite Representative: H Integrator:
Certified Operator: Va4rI Ck— /\)La( Certification Number:
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
Design Garrent
Swine Capacity Pop:
i _ Design Current '
ultry " Capacity Pop.
Wet PoVAN
La er
Cattie
Design
Capacity
C•nrrent
Pop.
Wean to Finish
Dairy Cow
Wean to Feeder
]Non -Layer
Dairy Calf
Feeder to Finish
Design Current
_ ll . 1'oult ; Ca aci P,o P.
Dairy Heifer
Farrow to Wean
2p
Dry Cow
Farrow to Feeder
Farrow to Finish
Non -Dairy
Beef Stocker
Layers
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Turkeys
Beef Brood Cow
Other
Turkey Poults
OF-Fther
Other
Discharges and Stream Imnacts
1. Is any discharge observed from any part of the operation?
❑ Yes
M No
❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
❑ Yes
❑ No
NA
❑ NE
b. Did the discharge reach waters of the State? (if yes, notify DWR)
❑ Yes
❑ No
[� NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWR)
❑ Yes
❑ No
R NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
F5] No
❑ NA
❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters
❑ Yes
5g No
❑ NA
❑ NE
of the State other than from a discharge?
Page 1 of 3 21412014 Continued

Facility Number: - ?3 �Date of inspection: i
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes R No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No 5] NA [] NE
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): V 11
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes N 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
M 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
(I No
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
[55 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 Apolication
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
V9 No
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes M No ❑ NA
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Ai
12. Crop Type(s):
❑ NE
13. Soil Type(s): l-OW
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
M No
0 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
�j No
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
[4 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
❑ 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 21412014 Continued

Facull Number: jDate of Ins ection:
I
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
F] No
❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check
❑ Ycs
P No
❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey [:]Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge?
❑ Yes
® 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?
29. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
® No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
[:]Yes
No
❑ NA
❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Yes
] No
❑ NA
❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAVIMP?
❑ Yes
[P 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
K] No
❑ NA
❑ NE
omments. (refer to ques�on`#� Explain any YES answers andlor any additional -recommendations ,or any other comments
rbsedrawings
of facility to better explain situations (use additional pages as necessary).
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: q/D`33�Ii�
Date: 11 l iI13
214120I4

E Iyvt Q
IS4
type 01 visit: W t;ompnance inspection V operation rceveew V Ntructure Evaluation U 'fecdnical Assistance I
Reason for Visit: i Routine O Complaint O Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit: Arrival Time:�� Departure Time: b p County: p Region: �!w
Farm Name: Owner Email:
Owner Name: �� �'' *1,s OA c, Phone:
Mailing Address:
Physical Address:
�—
Facility Contact: J0-�"s Title:
Onsite Representative: ti
Certified Operator: _ Aw
Back-up Operator:
Location of Farm:
Phone:
Integrator: fYS
Certification Number:
Certification Number:
Latitude: Longitude:
Design Current
Design
Current
Current
Swine
Capacity Pop.
Wet EouItry
Capacity
Pop.
MEDesign
Cattle Capacity Pop.
Wean to Finish
Layer
Dairy Cow
Wean to Feeder
Non -La er
Dairy Calf
Feeder to Finish
—"
Dairy Heifer
Farrow to Wean
U00
Design
Current
Dry Cow
Farrow to Feeder
Non-Dai
Farrow to Finish
Layers
Beef Stocker
Gilts
HPullets
Non -Layers
I I.Beef Feeder
Boars
Beef Brood Cow
Turkeys
Other
Turkey Poults
Other
Other
Discharees and Stream impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
❑ Yes W No ❑ NA ❑ NE
❑ Yes
❑ No
® NA
❑ NE
❑Yes
[:]No
�NA
❑NE
❑ Yes ❑ No ® NA ❑ NE
❑ Yes No T❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
Page 1 of 3 21412011 Continued

_ s
Facili Number: jDate of Inspection: ZI
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
No
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No
® NA
❑ NE
Structure 1 Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier: T
Spillway?:
Designed Freeboard (in):
rJ
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
No
❑ NA
❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a
❑ Yes]
No
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat,
notify DWQ
7. Do any of the structures need maintenance or improvement?
❑ Yes
® 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)
T
9. Does any part of the waste management system other than the waste structures require
❑ Yes
No
❑ NA
❑ NE
maintenance or improvement?
T
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
® No
❑ NA
❑ NE
maintenance or improvement?
iP
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. [] Yes F No ❑ NA
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of A�
12. Crop Type(s):
❑ NE
13. Soil Types):
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes 4 No ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes Po No ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes ® No ❑ NA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
❑ Yes p] 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 �1] No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check [] Yes ® No [] NA ❑ NE
the appropriate box.
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑ Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes 0 No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall []Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 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 of3 21412011 Continued

Facility Number: - Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes F4 No
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check [] Yes 09 No
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge? ❑ Yes EP 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 itnmediately.
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
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ Yes q No ❑ NA ❑ NE
❑Yes ®No ❑NA ❑NE
❑ Yes J4 No ❑ NA ❑ NE
❑ Yes )n No ❑ NA ❑ NE
❑ Yes No
❑ Yes ' No
❑ Yes �] No
❑NA ❑NE
❑ NA ❑ NE
❑ NA ❑ NE
Phone: AI'L—
Date: t 7a /0
21412011

type of vISM W [ ompuance inspection v uperanon tceview V ntrucrure Evaluanon V iecnmew Assistance
Reason for Visit: ® Routine O Complaint O Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit: Arrival Time: DZr Departure Time: County:}
Farm Name: 1`-'l lJ Owner Email:
Owner Name: `~ (Yl Phone:
Mailing Address:
Physical Address:
Facility Contact:
Title:
Onsite Representative:
Certified Operator: 3 r * 04,
Phone:
Certification Number:
Region:_
Integrator:
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
Design Current
Swine Capacity Pop.
Wean to Finish
Wet PoWtry
La er
Desiscits.
CapaPop.
urrent
Cattle
Dai Cow
Dai Calf
Design Current
Capacity Pop.
)OlFarrow
Wean to Feeder
zooDesign
Nan -La er
Dry P,oultr
Layers
Ca aci
Current
P.o .
Feeder to Finish
to Wean
airy Heifer
Cow
Farrow to Feeder
Farrow to Finish
Non -Dairy
Beef Stocker
Beef Feeder
113eef Brood Cow
I
Gilts
Non -Layers
+__J
Boars
Usher
Other
ram
Pullets
Turkeys
Turke Poults
Other
-
Discharees and Stream Imnacts
1, Is any discharge observed from any part of the operation?
❑ Yes
® No
❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
❑ Yes
❑ No
® NA
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWR)
❑ Yes
❑ No
® NA
❑ NE
c, What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWR)
❑ Yes
[:]No
F3 NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
R No
❑ NA
❑ NE
3, Were there any observable adverse impacts or potential adverse impacts to the waters
C] Yes
0 No
❑ NA
❑ NE
of the State other than from a discharge?
Page I of 3 21412014 Continued

Facili Number: - Date of inspection: I
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes QpNo DNA ❑ NE
a. If yes, is waste level into the structural freeboard? D Yes ❑ No ETNA ❑ 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
91 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
FPVNo
❑ 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
S 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
KNo
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
PNo
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes JE] 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 ❑ fEvidence of Wind Drift c ❑ Application Outside of Approved Area
12. Crop 7ype(s): i �1C�CfirQSS��CLt51 i11�C' 1
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
15. Does the receiving crop and/or land application site need improvement?
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
acres determination?
17. Does the facility lack adequate acreage for land application?
18, Is there a lack of properly operating waste application equipment?
Required Records &_Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
the appropriate box.
❑ Yes
No
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
❑ Yes
[ZNo
❑ NA
❑ NE
❑ Yes [? No ❑ NA ❑ NE
❑ Yes [4 No ❑ NA ❑ NE
❑Yes ®No ❑NA ❑NE
El Yes InNo El NA ❑NE
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes R 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 En No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes VNo
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
0 NA ❑ NE
Page 2 of 3 21412014 Continued

FaciHty Number: DateInspection: j j
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes ZpNo ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes RNo ❑ 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 ONo ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes fc7VNo ❑ NA ❑ NE
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern? ❑ Yes No ❑ NA] NE
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the [] Yes No ❑ NA ❑ NE -
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below. ❑ Yes Q 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 P No ❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes Vg No ❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency? ❑ Yes 117,1 No ❑ NA ❑ NE
Comments.. (refer to question .#): Ex lain any YES answers and/or any-add�honalrecommenlateons or any, o. ther 'c.a
mmens;
Use drawin of facilityto better explain m situations (use additional pages as necessary),
Reviewer/inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: Cf0 -A 33 `3 3&D
Date:
21412014

Type of visit: W Compliance Inspection V Operation Review U Structure Evaluation U Technical Assistance
Reason for Visit: 0 Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: js. Arrival Time: o3:3p n� Departure Time: �„ County: YNfK4gV Region:% I"�
Farm Name: r ~1 q T
Owner Name:
Mailing Address:
Physical Address:
Owner Email:
Phone:
Facility Contact: jfrQ"�� p #'' Title: Phone:
Onsite Representative: Integrator:�res-9e�
Certified Operator: - h ,�'� l4>�/S Certification Number.%
Back-up Operator: 1wl i"WC- �� 'V �R/ Certification Number:
Location of Farm:
Latitude:
Longitude:
r t r R
Deli n Currents Desi n Currrent u Design Current
Swine Caac�ty Pop. Wet Poultry CapacityPop Cattle Capacity Pop.
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
�n
Myer
Non -La er
DairyCow
DairyCalf
_
ate.
- Design Current
Dai Heifer
Cow
Non -Dairy
Farrow to Feeder
D . P,oult . Ca ci P,o
Farrow to Finish
La ers
Beef Stocker
Gilts
Nan -La ers
Beef Feeder
Boars
Pullets
Beef Brood Cow
a
Turkeys
[3ther
TurkeyPoults
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)?
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 P No ❑ NA ❑ NE
❑ Yes
[:]No
NA
❑ NE
❑ Yes
❑ No
NA
❑ NE
❑ Yes ❑ No NA ❑ NE
❑ Yes No ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
Page I of 3 21412011 Continued

Wacility Number: Ela, - Date of Inspection: Z
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
PNo
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No
�j NA
❑ NE
Structure 1 Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier:_
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
[;5 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
fS 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
[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
[P No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
® No
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? if yes, check the appropriate box below. ❑ Yes ® No
❑ NA
❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground
❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure
to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift
❑ Application Outside of Approved Area
jj
12. Crop Type(s): C-wsQ 'eerfYkd4 @,, -s „
,y�i� &wz,�j 66irw4rJ
13. Soil Type(s): L
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
MR 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 [P] No
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
Dq No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
® No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
® No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
No
❑ NA
❑ NE
the appropriate box.
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements
❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
No
❑ NA
❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis
❑ Waste Transfers
❑ Weather Code
❑ Rainfall [:]Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and I" Rainfall Inspections ❑ Sludge Survey
22, Did the facility fail to install and maintain a rain gauge?
❑ Yes
[P No
❑ NA
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
® No
❑ NA
❑ NE
Page 2 of 3
21412011 Continued

I'acili umber: jDate of Inspection: Z5 i
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes 119 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 El 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 W No ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? [ ] Yes 1 No ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes [�j 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 10 No ❑ NA ❑ NE
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the ❑ Yes No ❑ NA ❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Yes
No
❑ NA
❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
[:]Yes
No.
❑ NA
❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
® No
❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
[:]Yes
No
❑ NA
❑ NE
Comments (refer to question #): Explain any YES answers and/or any additional recommendations or any -other commeuts��oi�M' t
Use: drawings of,faciiityto better explain situations (use additional pages as necessary).
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: ��Q— 3-- 33DO
Date: g Z5 :-
2/412011

type of visit: 1p Compliance Inspection U Operation Review (_)Structure Evaluation U Technical Assistance
Reason for Visit: 1® Routine O Complaint O Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit:l Arrival Time: Departure Time: os400 County: Region:
Farm Name: P-19 T Owner Email:
Owner Name: Rrt��LS Phone:
IJ
Mailing Address:
Physical Address:
Facility Contact: Title: Phone:
Onsite Representative: �arr.,-Le Integrator:
Certified Operator: Certification Number: / 1
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
Design Current;
Swine Capacity Pop ^" Wet�Poultry
r
Wean to Finish La er
Design Current Design Current
Capacity Pop.• Cattle Capacity Pop.
DairyCow
Wean to Feeder Non -La er
DairyCalf
Feeder to Finish y ;* "'
arrow to Wean=- .
Design
*'
Current`•--..
DairyHeifer
D Cow
Farrow to Feeder Dr aPoultr
Ca _aci
yPo
Non -Dairy
Beef Stocker
Farrow to Finish Layers
Gilts Non -Layers
Beef Feeder
01
Boars
Pullets
Turkeys
Beef Brood Cow
Turkey Poults
Other
Other
Discharges and Stream ImDacts
l . 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
�] NA
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
❑ Yes ❑ No
F] NA
❑ WE
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
Dq NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes rWo
[] NA
❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters
❑ Yes IM No
[] NA
❑ NE
of the State other than from a discharge?
Page I of 3 21412011 Continued

Facility Number: - Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes
a. If yes, is waste level into the structural freeboard? ❑ Yes
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5
Identifier:
j� No ❑ NA ❑ NE
❑ No NA ❑ NE
Structure 6
Spillway?:
Designed Freeboard (in): Observed Freeboard (in): 36
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes No ❑ NA ❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a ❑ Yes No ❑ NA ❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7_ Do any of the structures need maintenance or improvement? ❑ Yes rnp No ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes EpNo ❑ 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 Qg 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 F,a No ❑ NA
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable
Crop Window. � ❑ Evidence ofWindDrift ❑ Appliccaattionn Outside of Approved Area
12. Crop Type(s): �--u{S w &Ir "'�t�' �� 6&5f� i � , G-� a �
❑ NE
13. Soil Type(s): C4at
3,
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes [P 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
M 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.
T
❑WUP ❑Checklists ❑Design ❑Maps ❑ Lease Agreements
❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
No
❑ NA
❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis
❑ Waste Transfers
❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rainfall Inspections
❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge?
❑ Yes
[ No
❑ NA
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
� No
❑ NA
❑ NE
Page 2 of 3
21412011 Continued

Faciti Number: jDate of Inspection: /
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 1P No ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge? ❑ Yes No ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes No ® NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
29, At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
34. Does the facility require a follow-up visit by the same agency?
❑ Yes � No
❑ Yes Rn T No
❑ NA ❑ NE
❑NA ❑NE/
❑ Yes C8 No ❑ NA ❑ NE-- --
❑ Yes Zj No ❑ NA ❑ NE
❑ Yes No
❑ Yes No
❑ Yes ® No
❑ NA ❑ NE
❑NA ❑NE
❑NA ❑NE
Comments (refer to question #}:. Explain any YES answers and/or any additionalrecommendations or anyiother comments.
Use_drawinQs_af facility to better explain -,situations fuse additional pazes.as necessary):.
C� 5 l�e� 0 k / r 16 -(/►
� .a, s t
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: 1 f7 ` ,3 "33M
Date: Q / � - r
21412011

Type of Visit • Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit 0 Routine O Complaint O Follow up O Referral O Emergency 0 Other ❑ Denied Access
Date of Visit:
Farm Name:
Arrival Time: Departure Time: Q County: Region:
POwner Email:
Owner Name: i�S-1c _ Phone:
Mailing Address:
Physical Address:
Facility Contact: _ T7411r_44_ Title: Phone No:
Onsite Representative: (1�0Integrator: "tie —
Certified Operator: 566Operator Certification Number: Q�"
Back-up Operator: Back-up Certification Number:
Location of Farm: Latitude: =1 0 0 I ❑ Longitude: = o = i
__-
D..esign Current
Swine CpaIity Population
Desigu - .Current
Wet Poultry CaparityPtoprilation Cattle
Design
Capacity
Current
Population
❑ Wean to Finish
10
Layer
❑Dairy Cow
❑ Wean to Feeder
10
Non -Layer I
airy Calf
❑ Feeder to Finish
- ❑Dairy Heifer
Dry Poultry El Dry Cow
ElNon-Dairy
Layers
El Beef Stocker
Non -Layers
Pullets ❑ Beef Feeder
❑ Beef Brood Cow
arrow to Wean
Farrow to Feeder
El Farrow to Finish
❑
❑
❑Gilts
❑ Boars
Turkeys
Number of Structures:
-
Other
❑ Other
❑
❑
❑
Turkey Poults
Other
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
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 F No ❑ NA ❑ NE
❑ Yes
❑ No
A
❑ NE
❑ Yes
❑ No
NA
❑ NE
P NA
❑ NE
❑ Yes
❑ No
❑ Yes
No
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
Page I of 3 12128104 Continued

• •
Facili Number:
h' Date of Inspection �
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
�No
❑ NA
El NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No
NA
F
El NE
St cture 1 Structure 2 Structure 3 Structure 4
Structure
5
Structure 6
Identifier:
Spillway?:
Designed Freeboard (in).
Observed Freeboard (in): d--
5. Are there any immediate threats to the integrity of any of the structures observed?
0 Yes
f 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
0 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
U No
❑ NA
❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit?
❑ Yes
No
❑ NA
❑ NE
(Not applicable to roofed pits, dry stacks and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require
❑ Yes
to No
[INA
ElN E
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes No ❑ NA ❑ NE
maintenance/improvement? )0
1. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes IN 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 Acceptable Crop Window PEvidence of Wind Drift Drift ❑+ Application Outside of Area
12. Crop type(s) aw7o &OW4
ay5e, (14r q),r '✓ ' a''IL,Gr ONI�eAw
13. Soil type(s) 04
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
P�No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
P5 No
❑ NA
❑ NE
lb. 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
TpCOVJs re✓tt'jej
/ o.
Reviewer/Inspector Name T' �`�M" Phone•
Reviewer/Inspector Signature: Date:
Page 2 of 3
121,2,410,i Continued

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 No ❑ NA ❑ NE
the appropriate box. ❑ WUP ❑ Checklists ❑ Design El Maps ❑Other
21. Does record keeping need improvement? if yes, check the appropriate box below. ❑ Yes taNo ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soi] 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
ONo
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
❑ No
P NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
)B No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
EgNo
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
(P No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
[] Yes
No
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30.
At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
31.
Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
P No
❑ NA
❑ NE
General Permit? (iel discharge. freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
�3 No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
RNo
❑ NA
❑ NE
AddifianalCominents and/or Drawings:
Page 3 of 3 12128104

Type of Visit 0 Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit O Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
ftj-
Date of Visit: Arrival Time: � Departure Time: """� County: Region: f �
Farm Name: Owner Email:
Owner Name: re _'T� Phone:
Mailing Address:
Physical Address:
Facility Contact: I ,, (( `� Title: Phone No:
Onsite Representative: UQ_ * � c_ Lail1 Integrator: �1 a -
Certified Operator: Skplex� AnA" Operator Certification Number: t_iQ —<SR
Back-up Operator:
Back-up Certification Number:
Location of Farm: Latitude: = = 0" Longitude: Elo = ' = u
Design
Swine Capacity
Current
Population
Design Current
Wet Poultry Capacity Population
Design Current
Cattle Capacity Population
❑ Wean to Finish
❑ Layer
❑ Dairy Cow
❑ an to Feeder
❑ Non -Layer-
❑ Dairy Calf
❑ Feeder to Finish
❑ Dairy Heifer
Farrow to Wean aonQ %g 3
Poultt y
❑ Dry Cow
Farrow to Feeder
❑ La ers
❑ Non -Dairy
❑ Farrow to Finish
❑ Beef Stocker
❑ Gilts
❑Non -La ers
El Beef Feeder
❑ Boars
El Pullets
❑ Beef Brood Cowl
❑ Turkeys
Other
❑ Other
❑ Turkey Poults
❑Other
Number of Structures:
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
Clo
❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
❑ Yes
❑ No
NA
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
❑ Yes
❑ No
(w 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
❑ No
NA
[INE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
No
ZNA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
No
❑ NA
❑ NE
other than from a discharge?
12128104
Continued

4
Facility Number:
Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. if yes, is waste level into the structural freeboard?
Structurei t Structure 2 Structure 3 Structure 4
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
❑ Yes r No ❑ NA ❑ NE
❑ Yes ❑ No DONA ❑ NE
Structure 5 Structure 6
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes �a El NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes (� No ❑ NA El NE
through a waste management or closure plan? r—
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes 0 No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit?
❑ Yes
FNo
❑ 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
�q No
❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
2rNo
❑ NA ❑ NE
maintenance/improvement?
11. 1s there evidence of incorrect application? If yes, check the appropriate box below.
❑ Yes
R No
❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu,
Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs ❑ Total Phosphorus [:]Failure to Incorporate Manure/Sludge into Bare Soil
[:]Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
Ar l a4 � SS �& Sint
��
©►' "r
12. Crop type(s) s ► {y'1'�[ �!
y+I�GGL
13. Soil type(s) W, 0
14. Do the receiving crops differ from those designated in the CAWMP?
❑ YesNo
ElNA ❑ NE
'No
15. Does the receiving crop and/or land application site need improvement?
El Yes
C3
❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination` ❑ Yes
El"NNo
❑ NA ❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
NNo
❑ NA ❑ NE
IS. Is there a lack of properly operating waste application equipment?
❑ Yes
,L✓_I
L►'S No
❑ NA ❑ NE
Comments (refer to question #): Explain any YES answers and/or any recommendations or any other comments.
Use drawings of facility to better explain situations. (use additional pages as necessary):
Reviewer/inspector Name AIMC Phone:
Reviewer/Inspector Signature: Date: 3
LZIZ6104 uonnnuea

Facility Number: — Date of Inspection
Required Records & Documents ,���,//
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ElCJ Yes No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CA WMP readily available? If yes, check ❑ Yes Ca No ❑ NA ❑ NE
the appropirate box. ❑ WUP ❑ Checklists ❑ Design ❑ Maps ❑ Other
21. Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
B No
❑ NA
❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and I"
Rain Inspections
Weather
Code
22. Did the facility fail to install and maintain a rain gauge?
❑ Yes
, !El
o
❑ NA
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
K,�3,<o
El NA
[I NE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
El Yes
i��Q,, NNo
El NA
El NE
25. Did the facility fail to conduct a sludge survey as required by the permit?
Yes
El93
'No
❑ NA
❑ WE
26. Did the facility fail to have an actively certified operator in charge?
❑ Yes
E No
❑ NA
❑ NE
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
rJ No
❑ NA
❑ NE
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
P IVo
❑ NA
❑ NE
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
b 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?
ElLI Yes
� �
No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
�,/
31. Did the facility fail to notify the regional office of emergency situations as required by
El Yes
0 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?
El Yes
,�/
C� No
❑ NA
❑ NE
33. Does facility require a follow-up visit by same agency?
❑ Yes
2Na
❑ NA
❑ NE
Page 3 of 3 12128104

J
Type of Visit B Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit S Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: �W Arrival Time: a r/S r+^� Departure Time: ✓�� County: s" =_ uesod Region:
Farm Name: -19l 2) Owner Email:
Owner Name: pPP[�Qi1^ S C, Phone:
Mailing Address:
Physical Address: L
Facility Contact: re V Title:
Onsite Representative:
Certified Operator:
Back-up Operator:
Phone No:
integrator:
Operator Certification Number:
Back-up Certification Number:
Location of Farm: Latitude: 0 n [� ; = cd Longitude: = ° = 4 [� <i
Destgn� Current
_ gnCurrent°
DlciPogrt Current
Swine
Capacity Population
Wet Poultry Caa aci� Po ulahan'C*attle
Ca ulationP t3P
Finish
❑ La er
❑ Dai Cow
Feeder
❑Non -La er❑Dai
Calf
Finish=❑
Dai Heifer
o Wean'"
ots
DP0lw
` ❑ D Cow
,�
o Feeder
0on-Dai
o Finish
aers❑Beef
Stocker
❑Non -La ers
El Beef Feeder
❑ Boars
❑ Pllets
u
❑ Beef Brood Co
Other"
,-
❑ Turkeys
❑ Other
❑ Turkey Poults
❑ Other
;
Number of 5truetures:
ILI
Masi
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes ll
❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
❑ Yes
❑ No
PqA
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
ElYes
❑ No
PNA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
❑ Yes
❑ No
ONA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
J§No
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
�Io
❑ NA
❑ NE
other than from a discharge?
Page 1 of 3
12128104
Continued

-f ft.
Facility Number: Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes PNo ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ONA ❑ NE
Structurg 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
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes No
❑ NA ❑ NE
through a waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes "id No
❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes JdNo
❑ NA ❑ NE
(Not applicable to roofed pits, dry stacks and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes No
❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes No
❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes $3 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) UCQ,- ( bE4'1A111A0 C-_n t Ss (I�aS-# e ), S Get.
13. Soil type(s) G�
r
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
[9 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
In No
❑ NA
[:1 NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
VS] No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
'R No
❑ NA
❑ NE
Reviewer/Inspector Name - Phone:
Reviewer/Inspector Signature: Date:
Page 2 of 3 12128104 Continued

Facility Number: 9,)%-2Y8 Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes ONo ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes [N No ❑ NA ❑ NE
the appropirate box_
❑ WUP El Checklists El Design El Maps El Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes 13 No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and I" Rain Inspections ❑ Weather Code
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes If No ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes &No ❑ NA ❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
5 No
❑ NA
❑ NE
25. Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
® No
❑ NA
❑ NE
26. Did the facility fail to have an actively certified operator in charge?
❑ Yes
T No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
09 No
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
19 No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
(--]Yes
19 No
❑ NA
❑ NE
and report the mortality rates that were higher than normal'?
30.
At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
31.
Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
No
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
No
❑ NA
❑ NE
Comments and/or Drawings:
12128104

Division of Water Quality
Facility Number a, 0 Division of Soil and Water Conservation
- 0 Other Agency
Type of Visit `{compliance Inspection O Operation Review Q Structure Evaluation 0 Technical Assistance
Reason for Visit Routine O Complaint Q Follow up O Referral O Emergency 0 Other ❑ Denied Access
Date of Visit: -1 Arrival Time: t �D 'Departure Time: G1: /}� County: Region:
Farm Name: _ — ! L b _ �Owner Email:
Owner Name: �741 MS Phone:
Mailing Address:
Physical Address:
Facility Contact:hflp_f��kTitle:
Onsite Representative:
Integrator:
Phone No:
Certified Operator: Operator Certification Number:
Back-up Operator:
Location of Farm:
Swine
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Other
❑ Other
Back-up Certification Number:
Latitude: 0 0 = = Longitude: = ° 0 ` = "
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer
I❑ Non -Layer
Dry Poultry
Non-L
Pullets
Poults
Discharges & Stream Impacts
I. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made'?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
Design CurreiiU
Cattle Capacity Population,
❑ Dairy Cow
❑ Dairy Calf
❑ Daia Heifej
UBDEXCow
❑ Non -Dairy
❑ Beef Stockei
❑ Beef Feeder
❑ Beef Brood Co
c. What is the estimated volume that reached waters of the State (gallons)?
Number of Structures: �1,
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
❑ Yes (Q No ❑ NA ❑ NE
❑ Yes
;X�No 4)NA
❑ NE
❑ Yes
[:]No 19 NA
❑ NE
❑ Yes
❑ No 2kNA
❑ NE
❑ Yes �N. ❑ NA ❑ NE
❑YesANo ❑NA ❑NE
12128104 Continued

117acilit Number`�%',A, —3 Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes 14 No ❑ NA ❑ NE
a. If yes, is waste level into the.structural freeboard? ❑ Yes JS No ❑ NA ❑ NE
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes
J�bNo
❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes
ANo
❑ 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
A No
❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes
A� No
❑ NA ❑ NE
(Not applicable to roofed pits, dry stacks and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes
No
❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes
ER No
❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes
kDNo
❑ 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 "e(s)
&t, G _ , N C"1 l /v h
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
ONo
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑YesRNo
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?❑ Yes
Kvo
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
Ons'No
❑ NA
❑ NE
18. is there a lack of properly operating waste application equipment?
❑ Yes
LINo
❑ NA
❑ NE
IComments (refer to question #): Explain any YES answers and/or any recommendations or any other comments. I
Use drawings of facility to better explain situations. (use additional pages as necessary):
C(m4 l ro frt,,rc
t� 1r1 `x or C_O Y t'.d
Reviewer/inspector Nam& ,—Af 1&O �STC>Q r *1L' Phone: - /a 7,'50 cSL�J
ReviewerAnspector Signature: Date: CW
12/28/0 Continued

Facility Number: — D Date of Inspection
Reid Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available?
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
the appropirate box.
❑ WUP El Checklists [I Design El Maps El Other
❑ Yes
1ANo
❑ NA
❑ NE
❑ Yes
�No
El
❑ NE
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes A No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rain Inspections ❑ Weather Code
22. Did the facility fail to install and maintain a rain gauge?
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
24. Did the facility fail to calibrate waste application equipment as required by the permit?
25. Did the facility fail to conduct a sludge survey as required by the permit?
26. Did the facility fail to have an actively certified operator in charge?
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
and report the mortality rates that were higher than normal?
30. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately
31. Did the facility fail to notify the regional office of emergency situations as required by
General Permit? (icl discharge, freeboard problems, over application)
32. Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
33. Does facility require a follow-up visit by same agency?
Additional Comments and/or Drawings:
❑ Yes
MNo
❑ NA
❑ NE
❑ Yes
❑ No �MNA
❑ NE
❑ Yes
RNo
❑ NA
❑ NE
❑ Yes
tiNo
❑ NA
❑ NE
❑ Yes
N No
❑ NA
❑ NE
❑ Yes ❑ No P NA ❑ NE
❑ Yes
[(No
r�
❑ NA
❑ NE
El Yes
No
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
El Yes
pfNo
❑ NA
❑ NE
❑ Yes
,b No
❑ NA
❑ NE
❑ Yes
�0 No
❑ NA
❑ NE
12128104

Di
vision.of Water
Fad Number •Division of Soil and Water Conservation
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: Q Arrival Time: ti Departure Time: County: ��� Region: ! -P-0
Farm Name:
Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: Title:
p
Onsite Representative: +
Certified Operator:
Back-up Operator:
Location of Farm:
Phone No:
Integrator: P"5g- _
moo.
Operator Certification Number:
Back-up Certification Number:
Latitude: = o = I = u Longitude: = ° = ,
Design Current Design Current Design C*urrent
Swine Capacity Population Wet Poultry Capacity Population. Cattle Capacity. Population
❑ Wean to Finish
❑ Wean to Feeder
ElFeeder to Finish
IV Farrow to Wean `d-000 ;_02( i
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
µ Other
4.
Other
❑ Layer
❑ Non -Layer
Dry Poultry
Layers
Non -Layers
Pullets
Turkeys
Turkey Poults
Other
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made'?
Dairy Cow
Dairy Calf
Dairy Heifer
Dry Cow
Non -Dairy;
Beef Stocker
Beef Feeder
Beef Brood C
Number of Structures:
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2_ Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
Page l of 3
❑ Yes VNo ❑ NA ❑ NE
❑ Yes
❑ No
HNA
❑ NE
❑ Yes
❑ No
[94A
❑ NE
Lg'NA
❑ NE
❑ Yes
❑ No
❑ Yes
to
❑ NA
❑ NE
❑ Yes
Q,<o
❑ NA
❑ NE
12128104 Continued

1 4
Facility Numher: Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes No ❑ N ElNE
a. If yes, is waste level into the structural freeboard? ElYes ❑ No NA ❑ NE
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?: p
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes �KNo ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes ZNo ❑ NA ❑ NE
through a waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement?
[:]Yes
QNo
❑ NA
❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit?
❑ Yes
❑ No
❑ NA
❑ NE
(Not applicable to roofed pits, dry stacks and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require
❑ Yes
❑ No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
EANo
❑ NA
❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes [P No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
12. Crop type(s) K t Swt .
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
[3 No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
❑ Yes
0 No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
[�RNo
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
[4 No
❑ NA
❑ NE
Comments (refer to question #)::Explain any YES answers and/or any recommendations or any other comments.
Use drawi©gs.of facility to better explain situations. (use additional pages as necessary):
Reviewer/Inspector Name (,� (t�-�-+ ..'{yyt,e .: Phone: D' -G8
Reviewer/Inspector Signature. Date:
Pape 2 or3 12128104 Continued

.
Facility Number: 9-- Date of Inspection
Required Records &_Documents %
19, Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes [N No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMIP readily available? If yes, check ❑ Yes No ❑ NA ❑ NE
the appropriate box.
❑ WUP ❑Checklists ❑Design El Maps El Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes �Q] 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 [A No ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes W No ❑ NA ❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
[P No
❑ NA
❑ NE
25. Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
[A No
❑ NA
❑ NE
26. Did the facility fail to have an actively certified operator in charge?
❑ Yes
0 No
❑ NA
❑ NE
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
M No
❑ NA
❑ NE
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
WNo
El NA
El NE
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
r
Id No
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
31. Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
No
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
® No
❑ NA
❑ NE
33_ Does facility require a follow-up visit by same agency?
❑ Yes
® No
❑ NA
❑ NE
Additional. Comments and/or Drawings:
1
U>,N
Page 3 of 3 12128104

type of visit (!Compliance Inspection O Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit ® Routine O Complaint O Follow up O Referral O Emergency O Other ❑ Denied Access
Date of Visit: lxlq /Ar— I Arrival Time: //: oe Departure Time: County: So tv- A -a a+
Farm Name: C Lq 1 _ Owner Email:
Owner Name: __ r`e--L 4r� _ Phone:
Mailing Address:
Physical Address:
Facility Contact:
Title:
Phone No:
Region: 1�/2.0
Onsite Representative: _ Q 6K GLI. 1342y,t'eat _ Integrator:
Certified Operator: _ s i.,kvw v� I a Operator Certification Number: IL
Back-up Operator:
Location of Farm:
Swine
Back-up Certification Number:
Latitude: =1 o =1 Longitude: =° =1 ❑ u
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Laver
❑ Non -La et
❑
Wean to Finish
❑
Wean to Feeder
El
Feeder to Finish
®
Farrow to Wean
ood
,2 0 3
❑
Farrow to Feeder
❑
Farrow to Finish
❑
Gilts
❑
Boars
Other
❑ Other
Dry Poultry
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ urkey Poults
❑ Other
Di_scharp,es & Stream Impacts
I _ Is any discharge observed from any pan of the operation'?
Discharge originated at: ❑ Structure El Application Field El Other
a. Was the conveyance man-made?
Design Current
Cattle Capacity Population
❑
Dairy Coax
❑
Dairy Calf
❑
Dairy Heifer
❑
Dry Cow
❑
Non -Dairy
❑
Beef Stocker
❑
Beef Feeder
❑
Beef Brood Cowl
Dumber of Structures:
b. Did the discharge reach waters of the State? (If yes. notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
❑ Yes [X No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
No
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
12128104 Continued

Facility Number: Sa _3Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes ® No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structure I Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier:
Spillway?:
Designed Freeboard (in): . — / 7 0
Observed Freeboard (in):1 r
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
® No
❑ NA ❑ NE
(iel 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
M No
❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the pen -nit?
❑ Yes
0 No
❑ NA ❑ NE
(Not applicable to roofed pits, dry stacks and/or wet stacks)
9. Does any pan of the waste management system other than the waste structures require
❑ Yes
Q? No
❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
® No
❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below.
❑ Yes
V No
❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge
into
Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside
of Area
12. Crop type(s) 6G r.►� �i a_ 4 r a Brae �S
13. Soil type(s) ��-
14. Do the receiving crops differ from those designated in the CAIVMP?
❑ Yes
® No
❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
(0 No
❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination,[:] Yes
® No
❑ NA ❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
M No
❑ NA ❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
EXNo
❑ NA ❑ NE
r to questiona� EipL
fa c iI ity to i b et to r � eap lg
Reviewer/Inspector Name Phone: ,l
Reviewer/lnspector Signature: Date: ,
1 Z116104 c onrtnuea

Facility umber: p,2 -,3yg Date of Inspection ly f ar
Re(mired 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 N No ❑ NA ❑ NE
the appropirate box. ❑ WUP ❑ Checklists ❑ Design ❑ Maps ❑ Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes ❑ No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and I" Rain Inspections ❑ 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
[P No
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
�j No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
[A No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
T No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
Qa No
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
® No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
5d No
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30_
At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
31.
Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
No
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
® No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
® No
❑ NA
❑ NE
Additio00.LComritents-and/or Drawiiugs: , .F
�.,.. _
o2e?- 71AC Ids 19 Caw+f,lex InQa Oree rniM �92u41 C. -YCor +'I.rc@.
PC r..,', � � s , �a G � � 4 v w : ++Ca� -Fn r y.-, y.., ++-a �' [► a v c 1 '� S o w ,,,
12128104

Type of Visit ® Compliance Inspection O Operation Review O Lagoon Evaluation I
Reason for Visit ® Routine O Complaint O Follow up O Emergency Notification O Omer [] Denied Access
Facility Number Date or visit: .3- D- T'uv.e:
O Not erational 0 Below Threshold
Ufermitted DC.ert>ifiied M Conditionally Certified [3 Registered Date Last Operated or Above Threshold: ..... _._ ._......
Farm Name:�......------ -,.� .._.......� County: ... G �!�P �.' Z .......
.. F� d ....
Owner Name: pf �sTv Q Phone No:
Mailing Address: ) :�!._!Q.4..7�._ y..?.. G�111l"�..W�._ ----_W_---W...__W_
Facility Contact: ...h �� n�/_.._.W1�� _ Title:. __. _ _..QPhone No:
Onsite Representative:._....L1 S'Q n ..... &-f!cz &Ct......................_.............. Integrator:
Certified Operator S u,!� � ......� �'✓:... �o r^ _ Operator Certification Number:
Location of Farm:
Swine ❑ Poultry ❑ Cattle ❑ horse Latitude ' 6 46 Longitude ' 4 "
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation? ❑ Yes ❑ No
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made? ❑ Yes ❑ No
b. If discharge is observed, did it reach Water of the State? (If yes, notify DWQ) ❑ Yes ❑ No
c. If discharge is observed, what is the estimated flow in gal1min?
d. Does discharge bypass a lagoon system? (If yes, notify DWQ) ❑ Yes ❑ No
2. Is there evidence of past discharge from any part of the operation? ❑ Yes ❑ No
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes ❑ No
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway ❑ Yes ❑ No
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure G
Identifier:._.._.....__. __ _...._..__.. _._,...
Freeboard (inches):
12112103 Continued

I
Facility Number: -3q
Date of Inspection D O
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, j] Yes
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or ❑ Yes E o
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 l_'d<0
8. Does any part of the waste management system other than waste structures require maintenancelimprovement? ❑ Yes [jjNo
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level ❑ Yes M No
elevation markings?
Waste Application
10. Are there any buffers that need maintenance/improvement? ❑ Yes ONo
11. Is there evidence of over application? If yes, check the appropriate box below. ❑ Yes E�Ko
❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload ❑ Frozen Ground ❑ Copper and/or Zinc
12. Crop type Co,75YO/ -swall.'
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)? ❑ Yes ONO
14. a) Does the facility lack adequate acreage for land application? ❑ Yes �o
b) Does the facility need a wettable acre determination? ❑ Yes 0,4%
c) This facility is pended for a wettable acre determination? ❑ Yes Eg-NO
15. Does the receiving crop need improvement? ❑ Yes G-KO
16. Is there a lack of adequate waste application equipment? ❑ Yes ONO
Odor Issues
17. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below ❑ Yes ❑ No
liquid level of lagoon or storage pond with no agitation?
18. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes [E .No
19- Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt, ❑ Yes ONO
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 ❑lqo
Air Quality representative immediately.
Cornnieats refer to { gdgn #) Esplam YES answs and/or arty recoeadateo»s Qany�atherrnmts.TM_�
Use di awrags,ud fanlity to -better ezplaw-siMat3o_as. {¢se aadnteoaai es as netcessary} M.PI'eld Copy El Final Notes l _ 1
F ]4&l
H
Reviewer/Inspector
wer/InspectorNume e
Reviewer/Inspector Signature: Date: 3- U-

1
Facility Number: _? _ �w Date of Inspection
Required Records & Documents
21. Fail to have Certificate of Coverage & General Permit or other Permit readily available?
❑ Yes
EKo
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
O-N-0
23. Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
jwo
❑ 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
EKo
25. Did the facility fail to have a actively certified operator in charge?
❑ Yes
moo"
26. Fail to notify regional DWQ of emergency situations as required by General Permit?
(ie/ discharge, freeboard problems, over application)
❑ Yes
M�No
27. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes
Ed -No
28. Does facility require a follow-up visit by same agency?
❑ Yes
❑ O
29. Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
01 o
NPDES Permitted Facilities
30.
Is the facility covered under a NPDES Permit? (If no, skip questions 31-35)�es
❑ No
31.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ yes
OINO
32.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
-Ko
33.
Did the facility fail to conduct an annual sludge survey?
MAres
❑ No
34.
Did the facility fail to calibrate waste application equipment?
0,Yes
❑ No
35.
Does record keeping for NPDES required forms need improvement? If yes, check the appropriate box below.
❑ Yes
�o
❑ Stocking Farm ❑ Crop Yield Form ❑ Rainfall ❑ Inspection After 1" Rain
❑ 120 Minute Inspections ❑ Annual Certification Form
12112103

Division of sowand Watei;tdn ei vatlon Operation Review _ \V
E Division of Soil and Water Conservation `Compliance V ectiow--- - ,. N =
® Division of Water -Quality Coi ipliancerInspecdon :` T , -Q- F
s Other Agency Ope"ration Review ; x 4
14PRoutine Q Com saint Q Follow-up of DW2 inspection Q FOHOW-UR of DSWC review Q Other
Facility Number Z Date of Inspection RN
Time of Inspection 24 hr. (hh:mm)
© Permitted ® Certified Q Conditionally Certified © Registered 113 Not OperationalOperationall Date Last Operated:
Farm Name: .............. P:..._J9f.............................................. County:.......... .mot yPrtt wl-..................... ...... I ...............
.
Owner Name: ... ��.>?i!r.................................. Phone No:..... 9/O ,��2 77�
Facility Contact: ^*s�e. '. 41 ................ Title:............... .. �..._ .... Phone No: ...................................................
Mailing Address: ......P �....dT`......1...P..f... 'C..r�� lf......... iCGlJ ...................................................... ..........................
Onsite Representative:.....,[ '��1.... ?' f�l�L............................................... Integrator: ............................................ ..........................................
Certified Operator:........... Z9.4....,� .......................................... Operator Certification Number:.... ......................................
. .................
Location of Farm:
............................................................................................................. ...................................... ......... ................. ........ .............. ............. ...................... I ...... ...........
r
...........................................................................................................................................................................................................................................................
Latitude �� Longitude
„ Design Current Design Current_ Design Current
:Swine Ca acit Po ulation PoiiEtry _Capacity Population. • Cattle
y p Capacity Population
❑ Wean to Feeder
❑ Feeder to Finish
® Farrow to Wean
2G60
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts,
❑ boars
us L I _ ;-===*_I❑ Subsurface Drains Present II❑ Lagoon Area I❑ Spray Field Area 11-1
Traps ❑ No Liquid Waste Management System -
Discharges & Stream Impacts
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'?
d. Does discharge bypass a lagoon system? (If yes, notify DWQ)
2. Is there evidence of past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge?
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway
❑ Yes a No
❑ Yes [2No
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
❑ Yes E] No
Q Yes ❑ No
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure b
Identifier:
4
Freeboard (inches): ........... ..............
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion,
seepage, etc.)
3/23/99
❑ Yes N No
Continued on back

r a
IFacility Number: — I Date of Inspection
�J
6.
Are there structures on -site which are not properly addressed and/or managed through a waste management or
closure plan?
❑ Yes
*0
(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?
K-Yes
❑ No
8.
Does any part of the waste management system other than waste structures require maintenatice/iniprovement?
❑ Yes'qNo
9.
Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings?
❑ Yes
® No
Waste Application
10.
Are there any buffers that need maintenance/improvement?
❑ Yes
�ONo
11.
Is there evidence of over application? ❑ Excessive Ponding ❑ PAN
❑ Yes
® No
12.
Crop type me, _ �i�/CI.Pr4l�
13.
Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)?
❑ Yes
No
14.
a) Does the facility lack adequate acreage for land application?
❑ Yes
W No
b) Does the facility need a wettable acre determination?
❑ Yes
No
c) This facility is pended for a wettable acre determination?
❑ Yes
No
15,
Does the receiving crop need improvement?
❑ Yes
No
16_
Is there a lack of adequate waste application equipment?
❑ Yes
IKNo
Required Record-, & Documents
17.
Fail to have Certificate of Coverage & General Permit readily available?
❑ Yes
No
18.
Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?'
(ie/ WUP, checklists, design, maps, etc.)
❑ Yes
PNo
19.
Does record keeping need improvement? (ie/ irrigation, freeboard, waste analysis & soil sample reports)
❑ Yes
NNo
20.
Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
Nf No
21.
Did the facility fail to have a actively certified operator in charge?
❑ Yes
No
22.
Fail to notify regional DWQ of emergency situations as required by General Permit?
(ie/ discharge, freeboard problems, over application)
❑ Yes
® No
23.
Did ReviewerAnspector fail to discuss review/inspection with on -site representative?
❑ Yes
KNo
24.
Does facility require a follow-up visit by same agency? -
❑ Yes
F.No
25.
Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
�[No
�'Vo Yig�aticjris;or det�ciencies mere npted• di} ih9 this:visit' - Yoir ;wi.1l-receive fid futther. - . -
corres6 oiidei�ce: ahirtif this .visit . .. :
7 jam• [ /�Ji/y o... br.��o�s,� �✓�jtt//L 4�� f {y.Ca�lD.�J �s✓�
/r k. •N /•.a.., a+t� �4e
Reviewer/Inspector Name
t ,�.� � n• r. x"3'r .r ' _. __._:. r-t � .z�.tt �. -- �j x_ e� yr _ rw
Reviewer/Inspector Signature: � �—' � Date: AV.? 9 y M
3/23/99

y �
Facility Number: Z — �' Date of Inspection f -9
Odor Issues
26. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below ❑ Yes 46P
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes A No
28. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt, ❑ Yes ® No
roads, building structure, and/or public property)
29. Is the land application spray system intake not located near the liquid surface of the lagoon? ❑ Yes 29 No
30. Were any major maintenance problems with the ventilation fan(s) noted? (i-e. broken fan belts, missing or
or broken fan blade(s), inoperable shutters, etc.) ❑ Yes ® No
31. Do the animals feed storage bins fail to have appropriate cover? ❑ Yes [gNo
32. Do the flush tanks lack a submerged fill pipe or a permanent/temporary cover? ❑ Yes eo
-Additional-Co & an oirrawtngs:.
3/23/99

r-
s CAROLI NA DEPARTM3W OF ENVIRONMENT, HEALTH' a NATURAL R$ROURCFS
DIVISICK Or ENVIRONMENTAL XMNAGE NEWT
Fayetteville Regional Office
Animal Operation Compliance Inspection Fora
..-a.�o^.«r�°`. "'�` �����.p //�yo�',yM":�'.`ap".�:c`acr •._"- =a-` ..r_
uy�;,;.4'=,3.-^��.M�SbI,VA�tF�i1��0•':t �%i'"11
�'r d°',3:�Y.�u.�^.• - FJ:v:�.
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^'L.r ^.w
r"^"���Tl�r.-�;
ii EfL�iS. t�W�`.a
.'S IIIISH>�+"v:.F..
11C1ZZTY'..'PHONE I`
�w.w."�.ro:.>-•o> �^. li[fs_a.�-i�ti7 ..�iiJliLCr7.7.. .a.•`y^r• :4ohunH!,s,"
wao�r�,
v c�
Cbn�n Z z
C L S��-���1
All questions answered negatively Will be discussed in sufficient detail in
the -Comments section to enable the deemed Permittee to perform the appropriate
corrections:
SECTION I
Animal Operation rorro v
Horses, cattle, swine poultry, or sheep
SECTION iI
Y I N I COMMENTS
7. Does the number and type of animal meet or exceed
the (.0217) criteria? (Cattle (100 head),
horses (75), swine (250), sheep (1,000),.and
poultry (30,000 birds with liquid waste
system))
2. Does this facility meet criteria for
Animal Operation REGIT ATION?
3. Are animals confined fed or maintained
in this facility for a 12-month period?
4_ Does this facility have a CERTIYIF.D AHIlsliL
WASTE x] gZffg l'P PLAW.
5. Does this facility maintain waste management
records (volumes of manure, land applied,
spray irrigated on specific acreage with
specific cover crop)?
6. Does this facility meet the SCS minimum
setback criteria for neighboring houses,
wells, etc?

t
SEMOx Ixz
Field Site Management
1. Is animal Waste stockpiled Or lagoon
construction within 100 ft. of a USGS
Map Blue Line Stream?
2. is animal waste land applied or spray
irrigated within 25 ft. of a USGS Map
Blue Un Stream?
3. Does this facility have adequate acreage
on which to apply the waste?
4. Does the land application'site have a
cover crop in accordance'with the
(DTI-rICATION PLAN?
S. Is animal waste discharged into waters of
the state by maxi -made ditch, flushing system,
or other similar man-made devices?
6. Does the animal waste management at this
farm adhere to Rest Management Practices
(BMP) of the approvedgggTMCATXW-
7- Does animal Waste lagoon have sufficient
freeboard? How much? (Approximately )
B. Is the general condition of this CAFO facility,
including management and operation,
satisfactory?
SEGSrON TV
Comments

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ANIM=Z W ST! NU MIT FLAX C3RT=7ICXT=ON YCR N$W OR 8X2A2iDEO PSLOLOTS
Please return the eomplated to=m to the Division of Znviroraeatal Hanagamamt at
the add=esa an the reverse side of this for=.
Name of farm (Please print) , ePQ- ;A6€ F4RmS_ _ric. P-19D
,address P.D. 80% *A--
C41n7bn /IZ Zja Phone No.: 910 Z 92 - T 77 1
County: SAMPSOn
Farm location: Latitude and Longitude:11'W fS"/, rmAa"(rei^A ed) . Also,
please attach a copy of a county road map with location identified.
Type of operation (swine, layer, dairy, ecc.) T_iJ-IM
Lesion capacity (ru Ser of animals) Z000 F=ARRow- WKAn _
Average size of operation (12 month population. avg.) 2000 FARRaw(- V1E4n
Average acreage needed for land application of waste (acres) 55 -
aaAaaawaaamaaaaaaammnsaMsaaaaaaaa:saaaaasaaaaazq xn asasaaaaa axx Mo as
_600-.,ical specialist caZ--ifiaation
As a catch .ical specialist. designated by the North Carolina Soil and Water
Conservation Commission pursuant to IM NCAC 6i -0005, 1 certify that the new or
expanded animal waste management system as inwa1? ed for a 'a= :sensed above
has as animal waste zonagement plan that meets the design, construction,
operation and maintenance standards and spec_ficat'_ors of the Division of
nvironmental management and the USCA-Sail Conservation Service anal/or the North
Carolina Soil and Water Conservation Commission purstant to 15A NCAC iH.0217 and
15A NCAC 6F .0001-.0005. The following elements and their corresponding aiaimu-a
iteria-haue�een verified by me or other designated technical specialists and
are included in the plan as applicable: minimum separations (buffers) ; liners or
equivalent for lagoons or :caste storage ponds; waste storage capacity; adequate
quantity and amount of land for waste utilization (or use of third party) ; access
or ownership of proper waste application equipment;.schedule for timing of
applications; application rates; loading rates; and the control of the discharge
of pollutants from stor.:. water runoff events less severe. than the 25-_year, 24-hour
storm.
Hama of Tech,i cal Specialist (Please Print) : G. G! E n r1 C L I FTon
Affiliation QQ�/s6g F.df{,rnS :Z, c.
Address (Agency) : P. o. 6 o S43 B � GL�IITo r] n G �2$31S2licne ,jo .4_�� R32- -97 7 /
Sig:.at,.=9: Care:-
1 (we) understand -the operation and maintenance procedures established in the
approved animal waste management plan for the fa_•� named above and will Implement
these procedures. 11 (we) know that any additional expansion to the existing
design capacity of the waste treatment and storage system or construction of new
facilities will require a new certification to be submitted to the Division of
Z,vironmental Maragemmnt before the new ani na? s are stocked. r (we) also
understand Vat there =ust be no discharge of animal waste from this system to
surface waters of the state either through a :man-made conveyance or th-rough
runoff from a storm event less severe than the 25-year, 24-1,.our storm. The
approved plan will he filed at the farm and at tie af=_ce or the local Soil and
Water Conservation Distri^Z.
(7 se rint) : PR65TAGE 00 VISA. Zn c
Signature: Date: S 1(D
Name of Han ar, is different From owner (Please print):
Signature:
Note: A change in land ownership requires
(if the approved plan is changed) to
Environmental Management within 60 days of
Date:
notification or a new certification
be submitted to the Division of
a title transfer.
0EX USE:

.V.._
Depertment of environment,
Health and Naturd Resources
Division of Environmental Mcnogement
Jcmes B. Hunt, Jr., Governor
Joncthan B. Howes, [ecretery
A. Preston Howard, Jr.. P.E., Direc*or
cm YCR '4 4 a3 ZX?-m=M A.W?Y.xL ? znLQTS
ZNSTRUC`-r:CNS F CR CERTI-ICATION OF APPQOV= AN!-MX , WASi- MA14AG-"INT PLXIS FOR
,^r- dR ? :ITiED A:I��.f,L `.dAS'I'_ *� ii:,Gc^.�:'; S'_'S'i'T.`4S Sc7VT24 =- - LOTS
7 a=7 ^�.'�.�Q / MIM 70 Qs
awrr -- -
,n or3er to be deemed permitted by the Division. o= Snvirorrental Management
(CEM), the owner of any new or expanded ar. .al waste management system
const=acted after January 1, 1994 which is designed to ser-re greater than or
equal to the an+ -al populations listed below is required to submit a signed
certification fora to DEM h&LQ-.1 the na- animals are stocked on the fa--=.
Pasture operations are exempt from the requirement to be terrified.
100 head of cattle
75 horses
2s0 somas
1,000 sheep
30,000 bi,-ds rrith a liquid waste system
The certification must be signed by the owner of the feedlot (and manager if
different from the owner) and by any technical specialist designated by the Sail
and Stater Conservation Commission pursuant to 15A NCAC 67 .0001-.0005. A
technical specialist must verify by an on -size inspection that all applicable
design and construction standards and specifications are met as installed and
that all applicable operation and maintenance standards and specifications can
he met.
Although the actual number of animals at the facility may va--,F from time to time,
the design capacity of the waste handling system should be used to determine if
a farm is subject to the certification requirement. For example, if the waste
system for a feedlot is designed to handle 300 hcgs but the average population
will be 200 hogs, then the waste management system requires a certification.
:'his certification is required by regulations geve_ning aniral waste :management
systems adopted by the environmental Management Cctm:ission (M C) on Lecemher 10.
1992 (Title 15A NCAC 2H .0217).
On the reverse side of this page is the cer_:Ficat:on fo^ which must be
suhztitted to OEM before new animals are stocked on the fart.. Assistance iz
C=-Plecinq the fora can be obtained from one of the local agricultural agencies
such as the soil and water conservation district, the USDA -Soil Ccr_servacion
Service, cr the N.C. Cooperative Zxtersion Service. The fora should be sent to:
uepartment of Environment, Healt2h and
Division of Environmental Management
Water Quality Section., Planning Branca
P.O. Box 29535
Raleigh, N.C. 27626-0535
Phone: [phone]
Fors ID: AC TE-- 0194
Natural Resources
1.t•G
Steve W. Tedder, Chief
Water Quality Section
Cate: /1'. 7.t /Sf3
P.4. 3cx 29535. Rde+gh. North Ccrofir-i 27626� Telephar,a 919-7;3-701f FAX [phone]
An Ec= Cccom- y A,`Tmcrive AcTion 'employer 50%recyc'.ec/ 1C% pes -c _r--m.;Mer ❑aoer