310833_INSPECTIONS_20171231

NORTH CAROLINA J
Department of Environmental Qual

k II Y'� 3.3
Type of Visit: t&FCom ' ce Inspection U Operation Review O Structure Evaluation Q Technical Assistance
Reason for Visit: Routine O Complaint O Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit: Arrival Time: Departure Time: County: Region:
Farm Name: Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Phone:
Facility Contact: / Title: Phone:
Onsite Representative: -n G r iM1 (r el Integrator:
Certified Operator: Certification Number:
Back-up Operator:
Location of Farm: Latitude:
Certification Number:
Longitude:
Design
Current
Design
Current
Current
I'Lupeslgn
Swine
Capacity
Pop.
Wet Poultry
Capacity
Pop.
Cattle
Capacity
Pop.
Wean to Finish
La er
Dairy Cow
We to Feeder
Non -Layer
Dairy Calf
ceder to Finish
J'Ley
i N9
Dairy Heifer
Farrow to Wean
Design
Current
Da Cow
Farrow to Feeder
D Poultr,
Ca aci
Po .,
Non -Dairy
Farrow to Finish
La ers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
ri
Beef Brood Cow
Turkeys
Other
Turkey Poults
Other
Other
Dischar es and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (if yes, notify DWR)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWR)
2. is there evidence of a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
❑ Yes No ❑ NA ❑ N E
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑✓ 1No ❑ NA ❑ NE
❑ Yes 64o ❑ NA ❑ NE
Page I of 3 21412015 Continued

7
Facility Number: Date of Inspection: Z,
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes �NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ 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 reat, notify DWR
7. Do any of the structures need maintenance or improvement? ❑ Yes NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes�N�oo NA ❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes E2<o ❑ 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?
l l . Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s):
14.
Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
M Now❑
NA
❑ NE
15.
Does the receiving crop and/or land application site need improvement?
❑ Yes
[;IQo
❑ NA
❑ NE
16.
Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
Q,
❑ NA
❑ NE
acres determination?
17.
Does the facility lack adequate acreage for land application?
❑ Yes
NA
❑ NE
18.
Is there a lack of properly operating waste application equipment?
❑ Yes
g>No
❑ NA
❑ NE
Re uired Records & Documents
19.
Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
No
NA
❑ NE
20.
Does the facility fail to have all components of the CAWMP readily available? If yes, check
Yes
o
❑ NA
❑ NE
the appropriate box.
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. [] Yes o ❑ 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 ludge Survey
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes zEl 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 21412015 Continued

Facili Number: - Date of Inspection: 2
24, Pid the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes Q-Nv--❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? Ifyes, check ❑ Yes [��Q NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge?
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
❑ Yes ❑-No ❑ NA ❑ NE
❑ Yes ❑ No NA - NE
❑ Yes Ea-N` ❑ NA ❑ NE
❑ Yes ❑-Ale—Q NA ❑ NE
❑ Yes ❑-N --Q NA ❑ NE
❑ Yes ❑-M—J` J, NA ❑ NE
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes [nTo ❑'NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes "o NA ❑ NE
34. Does the facility require a follow-up visit by the same agency? ❑ Yes [:]No ❑ NA ❑ NE
Comments (refer to'question,ft): Explainlnny YES,answers and/oriany,iadditionalirecommendatidns or,, other' comments
.!!#IFpa! €� �..lilo-. ! �1 .._E +! �., ,..�,$:e:aiC� ,:.Ear:- - ,i .: f' :€' F,aaf .l'V. ! _€.:3a s, ,I - .I-,"1 h '' �!_ '^ r,`' t•
Us_e drawin 's�of,ficility�'i �,6 _tteri,explam situations,(use'additional�pages as_rietessary),�.,
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3of3
lIC tI & 11 4
f/,� 7�
Phone:
Date: " l�
21412015

Type of Visit: 0 Co pliance Inspection O Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: ® Departure Time: County: Region:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact: Title:
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Wean to Finish
Wean to Feeder
Feeder to Finish
Z5
Farrow to Wean
Farrow to Feeder.
Farrow to Finish
Gilts
Boars
Other
Owner Email:
Phone:
Phone:
Integrator:
Certification Number: _ 1 1 �L�
Certification Number:
Latitude: Longitude:
Non -Layer
2 P„Oultry
Layers
Non -Layers
Pullets
Turkeys
Turkey Poults
Other
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
Dairy Cow
Dairy Calf
Dairy Heifer
Dry Cow
Non -Dairy
Beef Stocker
Beef Feeder
Beef Brood Cow
❑ Yes 0 No ❑ NA ❑ NE
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)
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 �rN
o ❑ NA ❑ NE
❑ Yes ❑ NA ❑ NE
❑ Yes o [] NA ❑ NE
Page 1 of 3 21412015 Continued

Facili Number: -"74 Date of Inspection: 6
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: jt
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 jNo ❑ 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 environmen I threat, notify DWR
7. Do any of the structures need maintenance or improvement? ❑ Yes o ❑ 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 E�(No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes ENo ❑ NA ❑ NE
t +9
mam enance or improvemen .
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes E�J/No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
E?(No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
V o
0 NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
No
❑ NA
❑ NE
acres determination?
r
17. Does the facility lack adequate acreage for land application?
❑ Yes
o
❑ 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
jN
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
❑ NA
❑ NE
the appropriate box.
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements
❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
6 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
❑ NA
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
❑ NA
❑ NE
Page 2 of 3
21412015 Continued

Facility Number: - Date of Inspection: 4P
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes No ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes No ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge? ❑ 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 the 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 Signatui
Page 3 of 3
❑ Yes C�No ❑ NA ❑ NE
❑ Yes ZNo ❑ NA [] NE
❑ Yes (�ZNo ❑ NA ❑ NE
❑ Yes
2(No
❑ NA
❑ NE
❑ Yes
[(No
❑ NA
❑ NE
❑ Yes
o
❑ NA
❑ NE
❑ Yes No ❑ NA ❑ NE
.ly
Date: �U
2/4 2015

Type of Visit: O CC pliance inspection V Operation Review O Structure Evaluation U Technical Assistance
Reason for Visit: Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0.,�D+enlied Access
Date of Visit: 1, Arrival Time: Departure Time: County: �uPL1SN Region:
Farm Name: Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact: Title:
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Phone:
Phone:
Integrator:
Certification Number: 113.2 6
Certification Number:
Longitude:
Swine
Wean to Finish
Design Current
Capacity Pop.
Wet Poultry
Layer
Design
Capacity
Current
Pop.
Design Current
Cattle Capacity Pap.
Dairy Cow
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Zb
Non -La er
D gy P,o_uItr,
Layers
I
Design
Ca �aci
Current
l;o
Dairy Calf
Dairy Heifer
Dry Cow
Non -Dairy
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
L_jOther
tither
I JEJ
Turke s
Turk Poults
10ther
Discharees and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify 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 Z No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes o ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
Page 1 of 3 21412014 Continued

Facility Number: 71 jDate of Inspection: C� / I las
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes o ❑ 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 0No ❑ 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 environmel�o
threat, notify DWR
7. Do any of the structures need maintenance or improvement? ❑ Yes ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes NNo ❑ 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 O/No [DNA ❑ 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 o
❑ NA
❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into
Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application
Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes o
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes o
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes No
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes I 'I No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes o
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes WNo
❑ 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 1" Rainfall Inspections ❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes I_JZ
N ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? [3 Yes ❑ NA ❑ NE
Page 2 of 3 21412014 Continued

Facility Number: - Date of Inspection: yr
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ YesgN
No ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey D 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 o ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes Io ❑ 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 CAWMP7
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 E2 No ❑ NA ❑ NE
❑ Yes [ No ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
❑ Yes
❑ Yes
❑ Yes
�N / ❑ NA NE
VNo
/ ❑ NA ❑ NE
❑ NA ❑ NE
(Comments (refer to question #). Explain any YES answers and/or any additional recommendations or any other comments. I
Use drawings of :facility to. Ibetter explain situations (use. additional pages as necessary). .
�.
Reviewer/Inspector Name:
Reviewer/Inspector Signatui
Page 3 of 3
Phone: k C
Date: 9 b�
2/ /2015

Reason for Visit: • VRoutine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: ' Arrival Time: Departure Time: County: X ( Region:
Farm Name: Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: / 7i Title: Phone:
Onsite Representative: JG 1V it& � 1 t ,tsi I r�— Integrator:
Certified Operator: Certification Number:
Back-up Operator: Certification Number:
Location of Farm: Latitude: Longitude:
Design Current
Design
Current
Design C►urrent
Swine Capacity Pop.
Wet Poultry
Capacity
Pop.
Cattle Capacity Pop.
Wean to Finish
La er
Dairy Cow
Wean to Feeder
Layer
Dairy Calf
Feeder to Finish ZU
(S
Dairy Heifer
Farrow to Wean
Design
Current
Dry Cow
Farrow to Feeder
Dr P�oultr,
C.a acit
Pao ,
Non -Dairy
Farrow to Finish
Layers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turke s
Other
Turkey Poults
Other
Other
Discharges and Stream 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 -27'No ❑ NA ❑ NE
[]Yes
[]No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
[:]Yes FN
NA ❑ NE
❑ Yes❑ NA ❑ NE
❑ Yes❑ NA ❑ NE
Page 1 of 3 21412011 Continued

Facility Number: - Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes ZNo ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):�
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes No ❑ NA ❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a ❑ Yes 2No ❑ 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 environment threat, notify DWR
7. Do any of the structures need maintenance or improvement? ❑ Yes ❑ NA [] NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes L✓J 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 Lu No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes ZNo ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes 0 No ❑ NA ❑ NE
[] Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
o ❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
❑ 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
❑ 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 K
I —]NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yesg/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 1" Rainfall Inspections Sludge Survey
22. Did the facility fail to install and maintain a rain gauge?
❑ Yes
❑ 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 21412014 Continued

l
Facili Number: - Date of Inspection:
24'' Did the facility fail to calibrate waste application equipment as required by the perr . ❑ Yes z ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check [:]Yes ZNo ❑ 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 Ef �zo
❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT") certification? []Yes ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes o ❑ NA
❑ NE
and report mortality rates that were higher than normal?
/No
29. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes ❑ 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 E2r 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 V<0 ❑ NA
❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes �No ❑ NA
❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes ZN�' ❑ NA
[3NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes ❑ NA
❑ NE
Comments (refer to question #): Explain any YES answers and/or.any additional recommendations or any other comments..
Use drawings of facility to better explain situations (use additional pages a's'necessary).
Reviewer/Inspector Name: jd Qoj
Phon : 1 j% X ` 3
Reviewer/Inspector Signature: _�..1�
Date:
Page 3 of 3
21412014

3
Type of Visit: VC_o%pliance Inspection O Operation Review Q Structure Evaluation Q Technical Assistance
Reason for Visit: (�Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit:4* Arrival Time: 1C)SO -7 Departure Time: [1[= County: j ( Region:
Farm Name: Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: Title: Phone:
Onsite Representative: -^`�UN /� I r�LlfZ Integrator:
Certified Operator: Certification Number: 1-7011-2 g
Back-up Operator: Certification Number:
Location of Farm: Latitude: Longitude:
Design Current
Design Current
Design C►urrent
wine Capacity Pop.
Wet Poultry
Capacity Pop.
Cattle
C►specify Pop.
rFZdertto
Wean o Finish
La er
DairyCow
an to Feeder
Non -La er
DairyCalf
Finish
Dairy Heifer
Farrow to Wean
Design Current
Dry Cow
Farrow to Feeder
Dr, P,oultr,.
Ca .aci l;o
Non -Dairy
Farrow to Finish
Layers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turke s
Other
Turkey Poults
Other
Other
Discharges and Stream lmoacts
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 7/No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes ❑ ❑ NA ❑ NE
❑ YesjpNo
❑ NA ❑ NE
❑ Yes ❑ NA ❑ NE
Page I of 3 21412011 Continued

Facility Number: 31- Date of Ins ection: 1 b 1t}
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
No
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No
❑ NA
❑ NE
Structure 1 Structure 2 Structure-3 Structure 4
Structure 5
Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): t�Z�
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
�o
❑ NA
❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a
❑ Yes
[Z/No
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat,
notify DWQ
7. Do any of the structures need maintenance or improvement?
❑ Yes
WNo
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
[;2'hIo
❑ 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
2rN/o
❑ NA
❑ NE
maintenance or improvement?
Waste Auplication
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
dNo
❑ NA
[] NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below.
❑ Yes
dNo
❑ NA
❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate
Manure/Sludge
into
Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes C3 No ❑ NA D 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 [3"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
F:�No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
�Io
❑ 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
[I 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
❑'X5
❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
[:I,/o
❑ NA ❑ NE
Page 2 of 3 21412011 Continued

Facility Number: - Date of Inspection: O
24'. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes No ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge? ❑ Yes ❑ 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 E!f 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 ZNo ❑ NA ❑ NE
If yes, contact a regional Air Quality representative immediately.
34. 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 o ❑ NA ❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes
34. Does the facility require a follow-up visit by the same agency? ❑ Yes
C Nc ❑ NA ❑ NE
❑NA ❑NE
No ❑ NA ❑ NE
Comments (refer to question #): Explain any YES answers and/or any additional recommendations or any other comments.
Use drawings of facility to'better explain situations (use additional pages as necessary).
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
�O N� rAp.,oG u,
Phone:(Q?Q " !3
Date: (� 2
2/4/2 II

Type of Visit: Q) C pliance Inspection O Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: e6Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
���u a .rr� rr irrrnrinnr� —.� i u���rrrr—
Date of Visit: Arrival Time:® Departure Time:® County: iDI/PLX#14 Region:
Farm Name: Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact:
Onsite Representative: G CNO 1<rCtid eo T
Certified Operator:
Title:
Phone:
Integrator:
Certification Number: -7 'ZZO
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
Design Current
Swine Capacity Pop.
Wean to Finish
Design Current Design Current
Wet Poultry Capacity Pop. Gattle Capacity Pop.
La er Dairy Cow
Wean to Feeder
Non -La er
Dairy Calf
Feeder to Finish
3LICI
Dairy Heifer
_:3LS1,o
Farrow to Wean
Design Current Dry Cow
Dro l;uultr. Ca aci P,o Non-Dai
rs Beef Stocker
Beef Feeder
ets Beef Brood Caw
Farrow to Feeder
Farrow to Finish
Gilts
Boars
�jj[fNo'ullaMen-Layers
Other
Other
Turke s
Turke Poults
Other
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation? ❑ Yes dNo ❑ NA ❑ NE
Discharge originated at; ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made? ❑ Yes ❑ No ❑ NA ❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
[] Yes ❑ No
❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWQ)
❑ Yes [:],No
❑ NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
[:)Yes gNo
o
❑ NA
[] NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters
[] Yes
❑ NA
❑ NE
of the State other than from a discharge?
Page I of 3 21412011 Continued

Facili Number: - Date of Ins ection: �J
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? [:]Yes No
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
Structure 1, Structure 2
6
❑ NA ❑ NE
❑ NA ❑ NE
Structure 3 Structure 4 Structure 5 Structure 6
5. Are there any immediate threats to the integrity of any of the structures observed?
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a
waste management or closure plan?
❑ Yes No ❑ NA ❑ NE
❑ Yes �No ❑ NA ❑ NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environment7 I threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes YNo
o ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑Yes ❑ NA ❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need [:)Yes No ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes � No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s): /
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
Q No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
a o
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
fNo
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
o
❑ 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
o
❑ 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 [3 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 o ❑ NA ❑ NE
23. if selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? 10Yes No ❑ NA ❑ NE
Page 2 of 3 21412011 Continued

[Facility Number: 113ate of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes ZNo ❑ NA ❑ NE
25. Is th yfacility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes 16 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 o ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes �VNo ❑ NA ❑ NE
Other Issues
28, Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes No
[DNA ❑ 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)
3 I. 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 �N
❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes I,GI too
❑ 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..recommendatiogs or any other comments
Use drawings of facility to better explain situations (use additional pages as necessary),
Sw o(-xE &WbI,c,0 /MA0-cN "I _L`
r'L` 5(-v0&-(- ilAWVW 9609,K
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone. [1
Date: =
21412011

Type of Visit: 0 Ca fiance Inspection Q Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: 94=
Arrival Time: Departure Time: U�E= County: OU Region:
Farm Name: Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact:
Title:
Onsite Representative: PA `"l _o-- �- Integrator:
Phone:
Certified Operator: Certification Number:
Back-up Operator:
Location of Farm: Latitude:
Wean to Finish
Wean to Feeder
NJ
JLaye.
Non -
Feeder to Finish 7,,6 liop
Farrow to Wean
Farrow to Feeder
Dr, I
Farrow to Finish
Laye
Boars I I INI (Pullets
Poults
Other I I IMI IOther
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
Certification Number:
Longitude:
Dairy Cow
Dairy Calf
Dairy Heifer
Dry Cow
Non -Dairy
Beef Stocker
Beef Feeder
Beef Brood Cow
❑ Yes 0 No ❑ NA ❑ NE
a. Was the conveyance man-made?
❑ Yes
❑ No
❑ NA
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
❑ Yes
❑ No
[]NA
[_]NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does 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 ❑ ❑ NA ❑ NE
❑ Yes FEIINXNo❑ NA ❑ NE
❑ Yes ❑ NA ❑ NE
Page 1 of 3 21412011 Continued

Facili hjumber: -
Ds ection- lD
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes ZN(o ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in)
S�truuctturree�I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
5. Are there any immediate threats to the integrity of any of the structures observed?
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a
waste management or closure plan?
❑ Yes 2 No ❑ NA ❑ NE
[:]Yes 2 f Xo ❑ NA ❑ NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environment I threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes WN ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes o ❑ NA ❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes JN o ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. [—]Yes No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload [] Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
o ❑ NA
to
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
N ❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
o ❑ 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
d o ❑ 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 1" Rainfall Inspections ❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? [:]Yes o ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes ][ No ❑ NA ❑ NE
Page 2 of 3 21412011 Continued

Facili tuber: - Date of Inspection: IL11;J11
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑Yes o ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes No ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge? ❑ Yes o ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes fNo ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes WNo ❑ 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 6No ❑ 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 Z o
❑ NA
❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes �o
❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes FZ/No
❑ NA
❑ NE
Comments (refer to question #): Explain any YES answers and/or any additional recommendations or any other comments...;
.
77-
Use drawings of facility to better explain situations (use additional pages as necessary).
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: (q�" 7 (d �� J b
Date: i6
kIn
21412011

flicilttyiNumbee,
Conseryat
t": 4VU01%1.4 iTV .a:+ tilt g..,51
Type of Visit 7Routine
pliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit O Complaint O Follow up O Referral O Emergency 0 Other ❑ Denied Access
Date of Visit: /O Arrival Time: ' Cy Departure Time: County: ��t? Region:
Farm Name: Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: Title: Phone No:
r
Onsite Representative: ° U A-T 6%0 M _—IJL£fL Integrator:
Certified Operator: Operator Certification Number: _
Back-up Operator: Back-up Certification Number:
Location of Farm: Latitude: = 0 0 t = 11
• Longitude: 0
M
`.S1 ���','��a��-t�ii.
Currenf : g(:a # i,V, 13esign< Current ` .. <`�� , g : Desigii� &yCarrent t
o. V..sl ,„j'z:-& s-. r's$" +$§. ,,:. t.7.i§k .i 3, '.bai?;...k Y: r.. 3'#_..' �,a. ea:.' �,.. nY 4 a $$.§
"Sw�nes
-Ca act
�', p y
P.o ulatiorrWetPoultry;Capacity;l?opulat�onCattley�{S�it�Capacity
P
,�"":,�::e'ik'
Popuon•
❑ Layer
❑ DairyCow
Non -Layer
❑ DairyCalf
zt'
(❑
+ " ���
; ❑ Dai Heifer
* Dry Poultr, J, �3, " r
D Cow
)❑
+� ti= : :� a
❑ Non -Dairy
❑ Layers
❑ Beef Stocker
❑ Non -Layers
❑Beef Feeder
❑ Pullets
".0 Beef Brood Cow
❑ Turke s
❑ Turke Pouets
F,
;
, .
a
4
�[ ❑Other ❑Other ,''t�Nurnber of�Struetu'res .
;. _-fir :'-
-4@
❑Wean to Finish
,e
s
` ❑ Wean to Feeder
Feeder to Finish
❑Farrow to Wean
El Farrow to Feeder
❑Farrow to Finish
w 'El Gilts
❑
gBoggars q
y
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
❑Yes
No
❑ NA
❑ NE
Discharge originated at; El Structure ❑Application Field ❑Other
a. Was the conveyance man-made?
❑Yes
❑ No
❑ NA
❑ NE
b.. Did the discharge reach waters of the State? (If yes, notify DWQ)
❑Yes
❑ No
❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
❑Yes
❑
❑ NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
El
VN
❑ NA
❑ N6
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑Yes
❑ NA
❑ NE
other than from a discharge?
Page 1 of 3
12/28/04
Continued

Facility Number: — 2331
Date of Inspection 16 1 ItJ
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Structure Ij Structure 2 Structure 3 Structure 4
Identifier: t`f
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): `
5. Are there any immediate threats to the integrity of any of the structures observed?
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
through a waste management or closure plan'?
❑ Yes No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
❑ Yes ElNA ❑ NE
ElYes No ❑ NA ❑ NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental th at, notify DWQ
7. Do any of the structures need maintenance or improvement? El Ye ❑ NA ❑ N
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes o ❑ NA ❑ N
(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 ❑ N
maintenance or improvement?
Waste Application /
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes ❑ No ❑ NA ❑ N
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes �No ❑ NA ❑ N
❑ 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
E
E
E
E
E
12. Crop type(s)
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
❑ Yes
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ? ❑ Yes
17. Does the facility lack adequate acreage for land application? ❑ Yes
18. Is there a lack of properly operating waste application equipment? ❑ Yes
CAN ❑ NA ❑ NE
1J o ❑NA El NE
o❑ NA❑ NE
Lf o ❑ NA ❑ NE
No ❑ NA ❑ NE
Comments(refer to question#) 'Explain any YES answers andloc any recommendations or any other comments
Used oftaci[ity to bette�explaitt situations;.(useadd�tional pageps-as necessary)1 ,
A,
q
Reviewer/Ins ector Name i � .k£ i 1 y ap
P s.. Tr
�7
Phone: lu--]3 D
r r^ , 5i
ReviewerAnspector Signature:
Date:
Page 2 of 3 1212NI04' Continued

Facility Number: — Date of Inspection / s
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available?
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
the appropriate box. ❑ WUP ❑ Checklists ❑ Design ❑Maps El Other
❑ Yes No ❑ NA ❑ NE
❑ Yes 111 No ❑ NA ❑ NE
21.
Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
O o ❑ NA
❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V
Rain inspections ❑ Weather Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
2 No ❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
]V El 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
El NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
VNo❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
LEI No ❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
Nc ❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
�Wo ❑ 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
o ❑ 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
NoJ ❑ 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
El NE
33.
Does facility require a follow-up visit by same agency?
El Yes
No ❑ NA
❑ NE
Additional Comments and/or Drawings: T
Page 3 of 3 12128104
Page 3 of 3 12128104

31
Type of Visit rRoutine
piiance Inspection O Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit O Complaint O Follow up O Referral O Emergency O Other ❑ Denied Access
Date of Visit: t 7 0 Arrival Time: I _J Departure Time: County: ,DUPIIIJ Region:
Farm Name: Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Phone:
Facility Contact: Title:
Onsite Representative: J°N aTHAA.3 M.-LLC- Integrator:
Certified Operator:
Phone No. -
Operator Certification Number:
Back-up Operator: I Back-up Certification Number:
Location of Farm: Latitude: = e 0 1 = Longitude: = ° = i = 1f
Design
Current Design Current Design Current
Swine
Cap sty
F 7P._U anon Wet Poultry Capacity Population C►attle Capacity PopulationR
❑ Wean to Finish
❑ La er
❑ Dairy Cow
❑ Wean to Feeder
Layer
❑ Dairy Calf
Feeder to Finish
-Lo
1j1.eo
❑ Dairy Heifer
❑ Farrow to Wean
Dry Poultry ❑ Dry Cow
❑ Non -Dairy
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Layers
❑ Beef Stocker
❑ Gilts
Non -Layers
❑ Beef Feeder
❑ Boars
❑ Pullets
❑ El Turkeys Beef Brood Cow,
Other
❑ Turkey Pou its
❑ Other
❑ Other Number of Structures:
Discharges &Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes�No
❑ NA
El NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made`?
❑ Yes
❑ No
❑ NA
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
❑ Yes
❑ No
❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
❑ Yes
❑ N
ElNA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
o
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
[�4
❑ NA
❑ NE
other than from a discharge?
Page 1 of 3
12128104
Continued

Facility Number: 3 — gj3 Date of Inspection t7 vs
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Structure I Structure 2 Structure 3 Structure 4
Identifier: t.A(ran- J
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): ' 1
5. Are there any immediate threats to the integrity of any of the structures observed?
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
through a waste management or closure plan?
❑ Yes �No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
[--]Yes No ❑ NA ❑ NE
❑ Yes ZNo ❑ NA ❑ NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmentalthreat, notify DWQ
7. Do any of the structures need maintenance or improvement? El Yes [ o ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes lJ 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 f4o ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes ZNo ❑ NA ❑ NE
maintenance/improvement? ,�
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes I_"1 No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 Ibs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
12. Crop type(s)
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
❑ No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
VNo
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?[] yes
[1No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑❑ Yes
Y❑
NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
Yes
:`NNbo
❑ NA
❑ NE
Comments �refer.to uestion # . fit lain.an YES answeMand/o roan recommendations or an other comments.t'3i€' y xts` y
,Use dr�awinygs'af��fgacEli[y][q$t}o�bxett$er expla[n�situya^vt►onYs..(use addrptia{,nnl„pages as necessary)- pw
S$`
� y
Reviewer/Inspector Name Phone:
ReviewerlInspector Signature: Date: 9 U7
Page 2 of 3 11,11261114 Continues

u
Facility Number: — g33 Date of Inspection l't
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available?
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
the appropriate box. ❑ WUP ❑ Checklists ❑ Design ❑ Maps ❑ Other
❑Yes L'JN ❑NA El NE
❑ Yes l �f No ❑ NA ❑ NE
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes D 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? El Yes No ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
[No
❑ NA
[INE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
ElYes
L�J o
❑ NA
El NE
25. Did the facility fail to conduct a sludge survey as required by the permit?
El Yes
20
❑ NA
❑ NE
26. Did the facility fail to have an actively certified operator in charge?
❑ Yes
2No
❑ NA
❑ NE
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
VNo
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes~
P�<o ❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
b<o ❑ 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
O No ❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
3 I.
Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
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
❑ NA
no,/[]
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
NA
❑ NE
i
Additional Comments4d/ anor Drawin s vt ,=i,'
L
12128104

Type of Visit Co pliance 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: � Arrival Time: ® Departure Time: County: vyl Region:
Farm Dame: I Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: Title:
Onsite Representative: J Am Aw 21L.E1Z
Certified Operator:
Back-up Operator:
Phone No:
Integrator:
Operator Certification Number:
Back-up Certification Number:
Location of Farm: Latitude: [= o = = {9 Longitude: 0 0 = ` 0
Design Current
Design Current
Design Current
Swine C►opacity Population
Wet Poultry C++opacity Population
Cattle Capacity Poplllation
❑ Wean to Finish
❑ Layer
❑ Dairy Cow
❑ Wean to Feeder
❑ Non -Layer
❑ Dairy Calf
Feeder to Finish
❑ Dairy Heifer
❑ Farrow to Wean
Dry Poultry
❑ Dry Cow
❑ Farrow to Feeder
❑ Non-Dai
❑ Farrow to Finish
❑ La ers
El Beef Stocker
❑ Gilts
on -Layers
[I Beef Feeder
❑ Boars
El Pullets
❑ Beef Brood Cow
El Turkeys
Other
❑ Turkey Points
❑ Other
❑ Other
Number of Structures.
Discharges & Stream Imoacts
1. Is any discharge observed from any part of the operation?
❑ Yes
Zo
❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
❑ Yes
❑ No
❑ NA
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
❑ Yes
❑ No
❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (if yes, notify DWQ)
❑ Yes
❑ o
El NA
[I NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
Yo
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
El yes
No
❑ NA
❑ NE
other than from a discharge`?
Page 1 of 3
12128104
Continued

Fftility Number. 3 3
Date of Inspection
Waste Collection & Treatment
4. is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Structure Structure 2 Structure 3 Structure 4
Identifier: Lip CAW`
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
through a waste management or closure plan?
❑ Yes C3Zo ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
❑ Yes dNo ❑ NA ❑ NE
❑ Yes to ❑ NA ❑ NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes [!(No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes ZNo ❑ 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 El Yes L�No El NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑Yes 2rN. ❑ NA ❑ NE
maintenance/improvement? �
11. Is there evidence of incorrect application? If yes, check the appropriate box below. El Yes EjN/o ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
12. Crop type(s)
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
ONo
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
No
[INA
El NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination? ❑ Yes
YN co
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
LdN
[I
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
No
No
❑ NA
❑ NE
.�4.i�
C0 rits�(refer to q�u�est�l�on #) Explai.n any l'ES answers and/or any recommendations or any other comments. _
F
?Use dr'awings:ol�facility t04lietti:r explain situations. (use additional pages as .necessary):s
Reviewer/inspector Name
',,, LJ �� . Phone{ -�
Reviewer/Inspector Signature:
Date:
Page 2 of 3 12128104 Continued

Facility Number: -- 33 Date of Inspection o
Required Records_& Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes �Zo
❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes ❑ NA ❑ NE
the appropirate box. ❑ WUP ❑ Checklists ❑ Design ❑Maps ❑Other
21. Does record keeping need improvement? if yes, check the appropriate box below. ❑ Yes 0 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 O No ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes L11 No ❑ NA ❑ NE
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
❑ Yes
[J'NNo
❑ NA
❑ NE
❑ Yes
LAN
❑ NA
❑ NE
ElYes
No
❑ NA
❑ NE
❑ Yes
' No
❑ NA
❑ NE
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
and report the mortality rates that were higher than normal?
30. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately
31. Did the facility fail to notify the regional office of emergency situations as required by
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
33. Does facility require a follow-up visit by same agency?
❑ Yes
[D No
ElNA
❑ NE
❑ Yes
dNo
❑ NA
❑ NE
❑ Yes
N
❑ NA
❑ NE
ElYes
❑ NA
❑ NE
�No
❑ Yes
No
❑ NA
El NE
El Yes
No
❑ NA
❑ NE
c ,tip
ts:andlor Drawings 4'' .��t. § aR ; :.: �•�� «
Additional Common � ,� . .,�.��� � ► �: �� '�ts::��� �: � A �c� � , .,�a
AL
t
Page 3 of 3 12128104

Facility Number
0 Division of Water Quality
Q Division of Soil and Water Conservation
.0 Other Agency
Type of Visit 6 com lance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other J.r❑ Denied Access
Date of Visit: �� t! 6 Arrival Time: I U Departure Time: County: i Region:
Farm Name: Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: �j Title:
Onsite Representative: t, d*ATE ►✓
Certified Operator:
Back-up Operator:
Location of Farm:
Swine
Wean to
Phone No:
Integrator:
Operator Certification Number:
Back-up Certification Number:
Latitude: = o = 6 Longitude: = ° 0 ` 0 "
Design : Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Laver
0 Non -Layer
bg Feeder to Finish 2A
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
Other
❑ Other
Dry Poultry
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ Turkey Pouets
❑ Other
Design Current
Cattle Capacity Population
❑ Dairy Cow
❑ Dairy Calf
❑ Dairy Heifer
❑ Dry Cow
❑ Non -Dal
❑ Beef Stocker
❑ Beef Feeder
❑ Beef Brood Co
Number of Structures:
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (if yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
❑ Yes No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes 7No
El NA ❑ NE
El Yes ❑ NA ❑ NE
12128104 Continued

Facility Number: — Date of Inspection !o ++
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Structure l 1 Structure 2 Structure 3 Structure 4
Identifier: (.+�(�/✓
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): I 1
5. Are there any immediate threats to the integrity of any of the structures observed?
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
through a waste management or closure plan?
[I Yes 6No El NA El NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
❑ Yes dNVNo
ElNA El NE
El Yes❑ NA ❑ NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental tto
notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes o ❑ NA ❑ NE
(Not applicable to roofed pits, dry stacks and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes Vo ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes ❑ NA El NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. El Yes;/No[:] NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN> 10% or 101bs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
12. Crop type(s)
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
ff
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
Yes
�rN
El NA
El 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
Vo
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
_[2'
7 -
❑ 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):
40
Reviewerllnspector Name O Phone 3
Reviewerllnspector Signature: Date: 6
/ .12128104 Continued

Facility Number: 3 j -p33 Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available?
<NNo
❑ Yes
0
El NA
El NE
20.
Does the facility fail to have all components of the CAWMP readily available? If yes, check
El Yes
❑ NA
NE
the appropirate box. ❑ WUP ❑ Checklists ❑ Design El Maps El Other
/No
21.
Does record keeping need improvement? If yes, check the appropriate box below.
❑Yes
ff
❑ NA
El 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?
ElYes
rl No
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
E16
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
LJ No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
�/7No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
PINo
❑ NA
❑ NE
Other ]slues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
o
(I NA
El 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
Z 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
EJ 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
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
No
❑ NA
❑ NE
Comments and/or Drawings:
12128104

IType of Visit ()-Cbmpliance Inspection 0 Operation Review 0 Structure Evaluation C) Technical Assistance
Reason for Visit 'Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: I Z= Arrival Time: 00 Departure Time: County:
Farm Name: _ZEL" lTl// Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact: Title:
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude: n°
Phone:
Integrator:
Operator Certification Number:
Back-up Certification Number:
Region:
Longitude: = ° =' =
Design C►urrent Design Current
Design Current
apacity Population Wet Poultry Capacity Population
C*attle
C►►opacity Population
an to Finish
❑ La er
❑ Dai Cow
❑ Dai Calf
an to Feeder
rE01
❑ Non -La er
der to Finish
❑Dai Heifer
row to Wean
Dry Poult❑
D Cow
row to Feeder
❑ Non -Dairy
El Farrow to Finish
❑ Layers
❑ Beef Stocker
❑Gilts
Non -Layers
❑ Beef Feeder
❑ Boars
❑ Pullets
❑ Turkeys
El Beef Brood Cow
Other
❑ Other
❑ Turkey Poults
❑ Other
Number of Structures:
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?
Page 1 of 3
❑ Yes ❑ 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: ` — 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 ❑ Maps ❑ Other
J21Does 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?
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
24. Did the facility fail to calibrate waste application equipment as required by the permit?
25. Did the facility fail to conduct a sludge survey as required by the permit?
26. Did the facility fail to have an actively certified operator in charge?
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
and report the mortality rates that were higher than normal?
30. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately
31. Did the facility fail to notify the regional office of emergency situations as required by
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
33. Does facility require a follow-up visit by same agency?
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Additional Comments an/dJ/or Drawings:
w
Xle��
J /c4 S �c� ✓�� Jar[/
zoo 7
Page 3 of 3 12128104

933
Type of Visit 0 Co Hance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: 2 �' a S Arrival Time: ® Departure Time: County:
Farm Name:
Owner Email:
Owner Name: Phone:
Mailing Address:
Physicat Address:
Facility Contact: Onsite Representative: CkO KkPkA_P, ) _.
Certified Operator:
Back-up Operator:
Location of Farm:
Swine
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Other
❑ Other
Title:
Phone No:
Integrator:
Operator Certification Number:
Back-up Certification Number:
Region:
Latitude: [= o = 4 = Longitude: ❑ ° ❑ 1 ❑
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer
II ❑Non -Layer I_
Dry Poultry
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ Turkey Poults
❑ Other
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
Design Current
Cattle Capacity Population
❑ Daia Cow
❑ Daia Calf
❑ Dairy Heifei
❑ Dry Cow
❑ Non -Dairy
❑ Beef Stocker
❑ Beef Feeder
❑ Beef Brood Cow
Number of Structures:
b. Did the discharge reach waters of the State'? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system'? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
❑ Yes No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
Z o
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
12128104 Continued

Facility Number: (late of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in): g
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes
[/ No ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes
❑ o ❑ 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
o ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ElYes
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
-❑ NA ❑ NE
maintenance/improvement?
;No
11. Is there evidence of incorrect application? if yes, check the appropriate box below. ❑Yes
❑ 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 WindowEl EvidenceJ of Wind Drifl El Application Outside of Area
n
12. Crop type(s) 6 & 5 - ` w Lotlo!"li
13. Soil type(s) GU T
14. Do the receiving crops differ from those designated in the CAWMP?
f
❑ Yes [�Zo
❑ NA
El NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination',[]
Yes EN
El NA
El NE
17. Does the facility lack adequate acreage for land application?
El Yes X' °
El NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
El Yes 7o
❑ NA
❑ NE
Comments (`referzto question #) *Explainlank YES iiswers:and/or anyNcommendations or an other comments.
Use�+drawings of'faeiLty to better explainjI
sifnationsa (use addihonalMages;as°necessary.
Reviewer/Inspector Name to i Phone: Cll 0
Reviewer/Inspector Signature: Date: b
12128104 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 El NA
❑ NE
the approprrate box. El ❑ Checklists ❑ Design [I Maps El Other
21.
Does record keeping need improvement? Ifyes, check the appropriate box below.
es
❑ No ❑ NA
❑ NE
❑ Waste Application ❑ Wee y Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Annual Certification
❑ Rainfall ❑ Stocking Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1"
Rain Inspections ❑ Weather
Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
No ❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
❑ NA
VNo
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
l.d No ❑ NA
❑
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification'?
El Yes
❑ No NA
NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
❑ N ❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
No ❑ NA
ElNE
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 ofemergency situations as required by
❑ Yes
ZNo., ❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
N ❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
No ❑ NA
❑ NE
Additional Comments and/or Drawings:
12128104

Date of Visit: Time: %3
facility Number
Not `Operational 0 Below Threshold
® Permitted ® Certified [3Conditlonally Certified 0 Registered Date Last Operated or Above Threshold:
Farm Name: Z- � ��� County: Aa
Owner Name:
Mailing Address:
Facility Contact:
Onsite Representative:
Certified Operator:
Location of Farm:
Title:
Phone No:
yPhone No:
Integrator: �✓• �� �J '
Operator Certification Number:
❑ Swine ❑ Poultry ❑ Cattle ❑ Horse Latitude 0' 6 K Longitude • 4 11
Design Current
Design Current Design Current
Swine Capacity Population
Poultry.
CapacitV Population Cattle Capacitv. . Population
❑ Wean to Feeder
❑ Layer
❑ Dairy
Feeder to Finish
I X2 d
I
JEJ Non -Layer
❑ Non -Dairy
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Other
❑ Farrow to Finish
Total Design Capacity
❑ Gilts
❑ Boars
Total SSLW
Ngumhcrrgf La ood8 ❑ No Liquid Waste Present ❑ Lagoon Area ❑ Spray Field Area
g Subsurface Drams
Holdm Ponds I Solid Traps 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? (Ifyes, 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?
st L Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway
Structure I Structure 2 Structure 3 Structure 4 Structure 5
Identifier: I
Freeboard (inches): x
05103101
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
Structure 6
Continued

Facility Number: _—/1Z Date of Inspection L&MV%�
5. Are there any immediate threats to the integrity of any of the structures observed? (iel trees, severe erosion,
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or
closure plan?
(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?
8. Does any pan of the waste management system other than waste structures require maintenance/improvement?
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings?
Waste ADnlication
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
10. .Are there any buffers that need maintenancerimprovement? ❑ Yes ❑ No
11. Is there evidence of over application? ❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload ❑ Yes ❑ No
12. Crop type $ f
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)? ❑ Yes ❑ No
14. a) Does the facility lack adequate acreage for land application? ❑ Yes ❑ No
b) Does the facility need a wettable acre determination? ❑ Yes ❑ No
c) This facility is pended for a wettable acre determination? ❑ Yes ❑ No
15.
Does the receiving crop need improvement?
❑ Yes
❑ No
16.
Is there a lack of adequate waste application equipment?
❑ Yes
❑ No
Re
ui ed Records & Docuinne-rits
17.
Fail to have Certificate of Coverage & General Permit or other 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
❑ No
19.
Does record keeping need improvement? (ie/ irrigation, freeboard, waste analysis & soil sample reports)
❑ Yes
❑ No
20.
Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
❑ No
21.
Did the facility fail to have a actively certified operator in charge?
❑ Yes
❑ No
22.
rail to notify regional DWQ of emergency situations as required by General Permit?
❑ Yes
❑ No
(ie. discharge, freeboard problems, over application)
23.
Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes
❑ No
24.
Does facility require a follow-up visit by same agency?
❑ Yes
❑ No
25.
Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
❑ No
© No violations or deficiencies were noted during this visit. You will receive no further correspondence about this visit.
6 a� ju;dry' ;
queson Erplatri.aity"YES tnswe'$IId/orany recvmceIIdattOn9'OC -a ty,,,0i3mtSskh*
CQIIlments;(refer tp .men
,
Gsc drawinrgKs. of facyiltty , to better explamps�iNtugtmnsy. (puse addut:onal pages as necessary} Fla+ ❑Field Gonv ❑ FinaI Notes
4°T {YCM..�1's•1�.Sw?iXYrwE..-UAF$IW414FF#1.�1''.`�i'^➢_.7'd3i15.4i,jp'°A'.ihti["1al�: d..+�•'�r++.+n1�w=.w�•• —. %itk'4f�:Iti:
se;/ fAwslk siojy moll kite
/�S T - 7y11f.3
&elio Afi,joWy ice,_ dvr✓ Aecc,45 3, t1r
l
Hw
e
Reviewer/Inspector Name �k`asw ,1� " E y!am�;' t t��a3 r ¢'� r� °c�
Reviewer/Inspector Signature: Date:
0510310I � T Cominued

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

Z'x
Type of Visit 12) Compliance Inspection O Operation Review Q Lagoon Evaluation I
Reason for Vlslt o Routine O Complaint O Fallow up 0 Emergency Notification 0 Other ❑ Denied Access
Facility Number Date of visit:
Ef Permitted [3 Certified D CondittioonallyCeCertified 13Registered
Farm Name: �L pL F f'I / itQliS
Owner Name:
Mailing Address:
Facility Contact: Title•
/}�
Onsite Representative: / /f myt-6 __vimYAt/__
Time:
Date Last Operat d or Above Threshold: _
C o u nty: 4AP41/�
Phone No:
Phone No:
Integrator:
Certified Operator: Operator Certification Number:
Location of Farm:
,,Z Swine ❑ Poultry ❑ Cattle ❑ Horse Latitude e t u Longitude & C 44
Discharees & Stream lmnacts
1. Is any discharge observed from any part of the operation? ❑ Yes ZNo
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)
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
Structure I Structure 2 Structure 3 Structure 4 Structure 5
Identifier:
Freeboard (inches): 3�
05103101
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes PrNo
❑ Yes iZ No
❑ Yes gNo
Structure S
Continued

Facility Number: Date of Inspection / D
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion,
❑ Yes
P�No
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or
❑ Yes
5�No
closure plan? (If any of questions 4-6 was answered yes, and the situation poses an
immediate public health or environmental threat, notify DWQ)
7. Do any of the structures need maintenance/improvement?
❑ Yes
O No
8. Does any part of the waste management system other than waste structures require maintenance/improvement?
❑ Yes
�(No
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings?
❑ Yes
VNo
Waste Application
10. Are there any buffers that need maintenance/improvement?
❑ Yes
Yf No
? ❑ Excessive Ponding ❑ BAN ❑ Hydraulic Overload
11. Is there evidence of over applicatiotopv�
❑ Yes
0 No
12. Crop type Qv CO
-r
F A A
13. Do the receiving crops differ with those designated in the Certified Animal Waste Managem t Plan (CAMP)?
❑ Yes
ZNo
14. a) Does the facility lack adequate acreage for land application?
❑ Yes
O 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
9 No
Re 'red Records & Documents
17. Fail to have Certificate of Coverage & General Permit or other Permit readily available?
❑ Yes
71 No
18. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.)
❑ Yes
No
19, Does record keeping need improvement? (ie/ irrigation, freeboard, waste analysis & soil sample reports)
Z Yes
❑ No
20. Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
VrNo
21. Did the facility fail to have a actively certified operator in charge?
❑ Yes
Z No
22. Fail to notify regional DWQ of emergency situations as required by General Permit?
❑ Yes
OfNo
(ie/ discharge, freeboard problems, over application)
23. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes
9No
24. Does facility require a follow-up visit by same agency?
❑ Yes
VNo
25. Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
ko
0 No violations or deficiencies were noted during this visit. You will receive no further correspondence about this visit.
Comments (refer to,question 0) Explaln any YES answers `and/ar any recommetidatiaos ar anvother comments 4 ° : 3 iF; i . `'E ,..
- a p f , .i�.w..w,.....u.:�....f......,��...,.,...a.u......_...:_.,._......_.�=s .-.
Use4rawtn s of fari tarty to better explainesttnations.,{nse,addibon pages as necessa3ryE) E: Field Conv El Final Notes
Y
AA�
1�5�re.-ram©r� ON Z f r� f o2. I�fl ��z Ncr �tFL �1k�1c , 7o�ay.
.x:a. ,""!'# .,�,.-J.q�gr• �1 ! '%-, "*'s;r-r r rI •`� --- ' ��i- —, -r,r .-wv .�..r-..,,.
Reviewer/Inspector Name
Reviewer/Inspector Signature: Date:
05103101 v f 1 Continued

Facility lumber: — Date of Inspccti(in
dor Issues
26. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge atior below
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of properly within 24 hours?
28, is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt,
roads, building structure, and/or public property)
k
29. Is the land application spray system intake not located near the liquid surface of the lagoon?
30. Were any major maintenance problems with the ventilation fan(s) noted? (i.e. broken fan belts, missing or
or broken fan blade(s), inoperable shutters, etc.)
31. Do the animals feed storage bins fail to have appropriate cover?
32. Do the flush tanks lack a submerged fill pipe or a permanentitemporary cover?
❑ Yes ;Z-ANo
❑ Yes 0 No
❑ Yes VNo
❑ Yes VNo'
❑ Yes A No
❑ Yes �f No
❑ Yes [1 No
Additiona] Comments,and/or'Draw•ings: iX!X
IR rCQR,o 1<rEpz Goe, ---rnQWO VErM EOT' acO
,p_--SoPG�AfJ� zFQ �t�p a`u � � 4D ILA i t
R E70 LA R El] R E- c D ce C) U 7 �# �i Frr► , 0 to rC sZ D!::p K)e' vr_=
o1J C
ru s ;r NC-. OD,
2001 viz
C V Fe 7�G.d D 1 eQRRiErQ-r
�Pr�Y� �PTzC�Zi-7�orJT�AN �rca ��Z�P�G:A-��©n!
MP'?
1JI�b�t.r�A-7 t' 61,�5 E� T
Pi nl�t_'I SZ'S �DR Z
0,91 7-o r
� _00 f T l� s�1VT
er
t�� Cfl � i1�ZF�r= ►✓T
! r2
rzF � �✓��►l Ty�ri1� �5� /�PPF��45 � �� �K,�y;�6�,g�/,�
05103101
d

Type of Visit /P Compliance Inspection 0 Operation Review 0 Lagoon Evaluation
Reason for Visit y6Routine 0 Complaint 0 Fallow up 0 Emergency Notification 0 Other ❑ Denied Access
Facility Number
Date of Visit: *0N=otOerational
Time:
Below Threshold
Permitted 0 Cer ified [3 Ctonally Certified 0 Registered Date Last Operat or Above Threshold:
ond'
Farm Name: G� County: Z„
Owner Name: ��� fG� ,/r►'�L G�i Phone No:
Mailing Address: 2636,E
Facility Contact: Title: Phone N
�c%�� S
Onsite Representative: �C _ ZLG _ _ Integrator:
Certified Operator: Operator Certification Number:
Location of Farm:
Swine []Poultry ❑ Cattle ❑ Horse Latitude 0 ' " Longitude 0 ° "
Design Current Design Current Design Current
Swine Ca acit Po ulation Poultry Capacity Population Cattle Capncitv Population
❑ Wean to Feeder 10 Layer I I El
Dairy
eeder to Finish ❑ Non -Layer] Non-Dai I
El Farrow to Wean - -
❑ Farrow to Feeder ❑ Other
_ ❑ Farrow to Finish Total Design Capacity
❑ Gilts
❑ Boars Total SSLW
.; -FMNg tuber of;Lagoons �" ❑Subsurface Drains Present ❑ Lagoon Area ❑ S ra Field Area
H oldrn Ponds 1 Solld Trap s ❑ 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 oll cti n & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway
Structure l Structure 2 Structure 3 Structure 4 Structure 5
Identifier:
Freeboard (inches):
0510,3101
❑ Yes ? NO
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
9Yes ❑ No
❑ Yes ONO
❑ Yes 0 No
Structure 6
Continued

Facility Number: ,3 — 3 Date of inspection 'z '
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, ❑ Yes ONO
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or
closure plan? El Yes No
(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? ElP Yes No
8. Does any part of the waste management system other than waste structures require maintenance/improvement? ❑ Yes P/l
o
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings? ❑ Yes A0
Waste_ Application
10, Are there any buffers that need maintenance/improvement? ❑ Yes ANo
11. Is there evidence of over application? I ❑ Excessive Ponding _ ❑ PAN .❑ Hydraulic,,Overl9v 1 ❑ Yes ONO
13.
Do the receiving crops differ with those designate in the Certified Animal Waste Management lan (CA P)?
❑ Yes
ONO
14.
a) Does the facility lack adequate acreage for land application?
❑ Yes
�rNo
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?
El)ZfNO Yes
RReguirrdJtecQrds
17.
& Documents
Fail to have Certificate of Coverage & General Permit or other Permit readily available?
❑ Yes
0No
18.
Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.)
[3 Yes
ONO
19.
Does record keeping need improvement? (ie/ irrigation, freeboard, waste analysis & soil sample reports)
Yes
❑ No
20.
Is facility not in compliance with any applicable setback criteria in effect at the time of design?
/❑ Yes
V!
21.
Did the facility fail to have a actively certified operator in charge?
❑ Yes
gNo
22.
Fail to notify regional DWQ of emergency situations as required by General Permit?
❑ Yes
(ie/ discharge, freeboard problems, over application)
'eNo
23.
Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes
No
�.(
24.
Does facility require a follow-up visit by same agency?
ElYes
25.
Were any additional problems noted which cause noncompliance of the Certified AWMP?
El Yes
No
0 No violations or deficiencies were noted
ddyduring this visit. You will receive no further correspondence about this visit.
%omments'(referr to 4ttestion #} Explain any:YE$ answer�s: and/or any recommendations or,any other camnients
tlise�drawings�afafacili, y to b'etterAexplaiu ltuations. (useWditional,,pages as�necessary). w A ^ Field Copy El Final Notes
an: cP.
F���m� �i�Kl �D�f'IUD
/]
r (NUctG C/YJLI�j✓ !/lf %^S�,DE�Y'-.,E D� .*�i1 C�
Reviewer/Inspector Name ;;.
Reviewer/Inspector Signature: 4 7171 Date: Wzjm' �_j
O5103101 `' Continued

Facility Number: — Date of Inspection Printed on: 7/21/2000
Odor Issues
26. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge atlor below ❑ Yes VNo
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of properly within 24 hours?
28. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt,
roads, building structure, and/or public property)
29. Is the land application spray system intake not located near the liquid surface of the lagoon?
30. Were any major maintenance problems with the ventilation fan(s) noted? (i.e. broken fan belts, missing or
or broken fan blade(s), inoperable shutters, etc.)
31. Do the animals feed storage bins fail to have appropriate cover?
32. Do the flush tanks lack a submerged fill pipe or a permanent/temporary cover?
❑ Yes / No
❑ Yes �No
❑ Yes XNO
❑ Yes (NNo
❑ Yes L 140
❑ Yes dNo
Additional,Uotnments and/or Drawings:
A,
j� (/t'�5�� /�i✓G SAS � S
-OWM9 70
AYM
, /�P 7�'�-- .r / Nv / 1��O 0. /� ARE
Vf%z �
xfelol
A zc-
22('
5100
IV

i]tvision of Water ualtt{i.I!}.-lv,r
I �.
'.
r ar`��
.T .. I yi. :� 4:
-
Division of Soil and Water Conservati
Oon
}
+
a
-...7
v.�}a� I �- 1 ✓' h Y tIMP
�T fi r�
'je i .143:r v'ilri
i�
ir.
�4A �t
l�o"B ,.
of Visit 0 Compliance inspection O Operation Review O Lagoon Evaluation
Reason for Visit ®Routine O Complaint O Follow up O Emergency Notification O Other ❑ Denied Access
Date of Visit: I i zrb Time: I._.J Printed on: 7/21/2000
Facility Number
Q Not Operational Q Below Threshold
0 Permitted M Certified 0 Conditionally Certified RegisteredPT Date Last Operated or Above Threshold: .............
Farm Name:........./..P�......r�1.!.5...........................:....................... County:...Pl f�!.•........................... ....%�0...
!�...................................................... Phone No:...
Owner Name: ..... N...l.zewx.�L........ 10.4— .L.l.. �....w.�Cl ��"(Ql�.............................
Facility Contact: ..... AlIelYA- l'..., 1.1-.L............Title: Q�rU.WT.� ........ Phone No :...................................................
........... ........ n. n /
Mailing Address: ..... �... /f�l l L %�`1 .. ... ../ ,......ti/% t ...� .. �!..'.. L' .'............ .....✓
,/,........ ,1..�.y.j...1.
Onsite Representative:....< 1..%.-er'I/!. v�r... /.Y! ril...............................I............. Integrator:.......!.........................
Certified Operator:....../ ,( .( f / l ..... (.t. .......................................... Operator Certification Number:.... Q.! ,�j•��,,,,,_„
Location of Farm:
So h')&40A/S A2)5J-....J
,Swine ❑ Poultry []Cattle ❑ Horse Latitude • F—b-73` I o_.•a 16 Longitude s• ®` ®"
Design Current
Design Current
Design Current
Swine Capacity Population
Poultry
Capacity Population Cattle
Capacity Population
❑ Wean to Feeder
JEI Layer
I
I
Dairy
Feeder to Finish
❑Non -Layer
Non- Dairy
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Other
❑ Farrow to Finish
Total Design Capacity
❑Gilts
Total SSLW
Zrb
❑ Boars
Number of Lagoons ❑ Subsurface Drains Present ❑ Lag-,,n Area ❑ Spray Field Area
Holding Ponds / Solid Traps ❑ No Liquid Waste Management System
Discharttes & Stream Impact;
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 conveyaiwe man-made? ❑Yes ❑ No
h. If discharge is ohservcd, did it reach Water of the State'! (If yes, notify DWQ) El Yes ❑ No
c. II' discharge is observed. what is the estimated slow in gal/rain?
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 j 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 l Structurc 2 Structure ; Structure 4 Structure 5 Structure 6
Identifier:...........��+............................................ .........................
...........................................................................................................................
Freeboard (inches):
5100 Continued on back

Facikity Number: — ij Date of Inspection f 5F/i]U Printed on.• 7/21/2000
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, ❑ Yes 9 No
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or
closure plan? ❑ Yes Amil No
(If any of questions 4-6 was answered yes, and the situation poses an
immediate public health or environmental threat, notify DWQ)
7. Do any of the structures need maintenance/improvement? ❑ Yes ,� No
8. Does any part of the waste management system other than waste structures require maintenance/improvement? ❑ Yes No
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 9No
11. Is there evidence of over application? ❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload ❑ Yes ZNo
12. Crop type n, AeMIJL)h- / OW'S
13. Do the receiving crops differ with those designated in the Certified, Animal Waste Management Plan (CAWMP)? ❑ Yes 0 No
14.
a) Does the facility lack adequate acreage for land application?
❑ Yes BNo
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 gNo ,
16.
Is there a lack of adequate waste application equipment?
❑ Yes ATNo
Required
Records & Documents
17.
Fail to have Certificate of Coverage & General Permit readily available?
❑ Yes A'No
18.
Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
❑ Yes
(ie/ WUP, checklists, design, maps, etc.)
,111rNo
19.
Does record keeping need improvement? (ic/ irrigation, freeboard, waste analysis & soil sample reports)
❑ Yes No
20.
Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes No
21.
Did the facility fail to have a actively certified operator in charge?
❑ Yes 9 No
22.
Fail to notify regional DWQ of emergency situations as required by General Permit?
❑ Yes ;j No
(ie/ discharge, freeboard problems, over application)
23.
Did Reviewer/Inspector fail to discuss review/inspection with on -site representative'?
❑ Yes No
24.
Does facility require a follow-up visit by same agency?
❑ Yes No
25.
Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes ( No
NO yielatio ... d fieien. iv�r. ... .. duritti� this;v�s�t; Your :will receive Iio; #'uf6 k -: -: •
• comes• ondence' a'botut.'this visit.: - * - ' - ..... .
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):
s�
A�
-- ,k/-C- 13 ro X&6P Al 6040- L"I"S ro 6) C_-h/&e_
IV
Reviewer/Inspector Name
Reviewerlinspector Signature: Date: %%P� i 5100

Facility Number: 3 — Date of Inspection // 1Odor ISSneti Printed on: 7/21/2000
�
26. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge M/or below ❑ Yes ►'`C' No
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes � No
28. Is there any evidence of wind drift during land application? (ix, residue on neighboring vegetation, asphalt, ❑ Yes No
roads, building structure, and/or public property) - 1
29. Is the land application spray system intake not located near the liquid surface of the lagoon? ❑ Yes 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 No
32. Do the flush tanks lack a submerged fill pipe or a permanent/temporary cover? ❑ Yes O No
Additional omments and/orDrawings:
5/00

Division of Soil and Water,Conservahon Operation Review 3 �
Q:Division of'Sol and,Water.ConserVahon Compliance Inspection f' ; s ,;
y �'HJ
3 3 Division•of'Water Quality, ,Comt Nance Ins ection. } E f '
.� I e p 3 p €�� i f�ra e.�FP o I� F f� , � �, >a-
}Iftotbek Agency-9peratron Review
�4F .},. Y, r. € �a: i3i•._I th:3 4 �s,, .. rad, S3}i
10
Routine O Complaint O Follow-up of DWO inspection O Follow -tit) of DSWC review O Other
I Facility Number I
Date of lnspection
Time of Inspection
24 hr. (hh:mm)
Permitted © Certifieed [3 Conditionally Certified © Registered Not O erational Date %Last Operated:
'Farm Name: ..... ...►.�yA....... .(-T............ol f%',�,.�.......................................................county:.. ..� .kf�':!.}�................,..............................
OwnerName:../...'..t.l.�%e.l........................ t Phone No:.......................................................................................
..................................................................
Facility Contact: Ili.d 1.............. All ............ Title: .... LY.t %` ... Phone No: ...........................
}Mailing Address: ..................................................................................................................... ................,.................................................................... ..........................
Onsite Representative:.. ...................................................Integrator:...4.1.c..C.......��/'�..................................
I
Certified Operator:;R.. l.................... A, // ................................... Operator Certification Number:..........................................
Location of Farm:
Latitude Longitude
Design Current ;Design ','Current Design Current
Swine Capacity Population., , Poultry Ca acity,.Population Cattle Ca' acit Population
❑ Wean to Feeder Layer ❑ Dairy
Feeder to Finish S-2-4 ❑ Non -Layer }, ❑ Non -Dairy
❑ Farrow to Wean
❑ Farrow to Feeder ❑Other y.
,,, ❑ Farrow to Finish Total Design Capacity
❑ Gilts
❑ _ Total'SSLW
Boars
7-1
, %' Number of !Lagoons,I ❑ „ Subsurface Drains Present ❑ Lagoon Area ❑ Spray Field Area
Holding' Ponds / Solid Traps ' o Liquid Waste Management System , r
Discharges & Stream Impacts
I. 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. Docs 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
Stn,cfmv I Structure 2 Structure 3 Structure 4 Structure 5
Identifier:
Freeboard(inches): ........ Z4................................................. ............................... ......................................... ................................... ..
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion,
seepage, etc.)
❑ Yes [9No
❑ Yes [X No
❑ Yes Va+ No
A/l/f"
❑ Yes' T No
❑ Yes [g No
❑ Yes IN No
[]Yes IX No
Structure 6
❑ -Yes %No
Continued on hack
3/23/99

Facility Number: 3 — Cr3' Date of Inspectiorr
6, Are there structures on -site which are not properly addressed and/or manaved through a waste managenicnt or
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'?
8. Does any part of the waste management system other than waste structures require maintenance/irmpt'cavernent'?
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings?
Waste Application
10, Are there any buffers that need maintenance/improvement'?
11. Is there evidences of over application? ❑ Excessive Ponding ElI'AN
12. Crop type CW_5 . A14 . Sr
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)?
14. a) Does the facility lack adequate acreage for land application?
b) Does the facility need a wettable acre determination'?
c) This facility is pended for a wettable acre determination'?
15. Does the receiving crop need improvement'?
16, Is there a lack of adequate waste application equipment'?
Required Records & Documents
17. Fail to have Certificate of Coverage & General Permit readily available?
18. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available'?
(ie/ WUP, checklists, design, maps. etc.)
19. Does record keeping need improvement! (ic/ irrigation, frechoard, waste analysis & soil sample reports)
20. Is fac:,ility not in compliance with any applicable setback crileria in effect at the time of design?
21. Did the facility fail to have a actively certified operator in charge'?
22. Fail to notify regional DWQ of emergency situations as required by General Permit?
(ie/ discharac, freeboard problems, over application)
23. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
24. Does facility require a Ibllow-up visit by same avency?
25. Were any additional problems noted which Cause noncompliance ol' the Certified AWMP'?
0: 10 yiol'at>foris:or• cteficiengp,s -wi► re'n6fedinning -(his visit' . Y:ou ;witl rectriye Rio, fuifthgr
..........
Cori- s�6ridence. ahout. this visit.. .. ' .. ' ... . .. ' ' . .
❑ Yes X No
❑ Yes ANo
❑ Yes ,1 No
❑ Yes PNo
❑ Yes 9 No
❑ Yes J4 No
❑ Yes P(No
❑ Yes 4 No
❑ Yes [R No
❑ Yes CK No
VYes ❑ No
❑ Yes K No
❑ Yes X No
❑ Yes j No
❑ Yes No
❑ Yes [XNo
❑ Yes 0 No
❑ Yes No
❑ Yes No
❑ Yes [X No
❑Yes tNo
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):
�(G Con-6;tm-e -1-e work: 4n bw-,r ara� in CagO-d A'e1o( —keep A �rL .i
We#We rc e h►J iV-PYL- v��-�,e✓nu �..c.� " A.s 100d &&V SApw;'�j
)W4AqJ)-c acre am,4,Ptdk- rk h.�.s WGI(�'`
r• ,�, ll Q:, ; �e� - e� (0Ni l h�
(Tk. $c.a
s We
Reviewer/]nspcctdr Name ree r-
Reviewer/inspector Signaturel� -AL „ _ —All, d, _ 1, Date:
�wQl9�Dl3�S- � a_--*i-Lzs- 3/23/99

Facility Number: 3 I)ate of Inspection
.Odor Issues
26. 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?
27. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes ANO
28. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt, ❑ Yes XNo
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 ,J10
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 to
31. Do the animals feed storage bins fail to have appropriate cover? ❑ Yes o
32. Do the flush tanks lack a submerged fill pipe or a permanentALmporary cover? ❑ Yes '�NO
tiona omtne is an gr rarv�ngs .. a >;� ;f € y,:
t n ,..,
3/23/99

0 Division of Soil and Water Conservation ❑ Other Agency
M_Division of Water Quality
ICI Routine O Conrolaint O Follow-uu of DWO insumflon O Follow-un of DSWC review O Other
Facility Number Date of Inspection
3
Time of Inspection FIT-0-7 24 hr. (hh:mtn)
© Registered 'Certified Applied for Permit © Permitted JE3 Not. Operational I Date Last Operated:
I__
Farm Nam :.......................... 3','..�'�e....{: County:........`............................... ..................
........... ...........
e Phone No:Z
Owner Name: .... WKSVI� ......L�...................................................................... .... �..L"... �° r ........................................
� 51...
I t � y
Facility Contact : ..............-......Ct.1.`��......................... Title: Phone No:� (^ 6J'y q,�-4 Y,ie
.......................
Mailing Address: ...�g�......�.!' .f ... ""l.. `....&. ................... . .� V.....1�� .......... ............ ..........................
` t......... .
Onsite Representative:__:' .!:!:� .............................................. .............. Integrator%.Zv. .... ...............
Certified Operator. ..................................................
Location of Tarm: I
r
....... Operator Certification Number:,,..........
­.. ....,,Z-1 ...................................... .... ..
Latitude C�•E='=11 Longitude
Design Current Design, : Current Design Currehit
Swine` Capacity Population" Poultry Capacity .'Population Cattle Capacity: Population
❑ Wean to Feeder
Feeder to Finish
G
7"1
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
General
1. Are there any buffers that need maintenance/improvement? ❑ Yes ((No
2. Is any discharge observed from any part of the operation? ❑ Yes XNo
Discharge originates! at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made?
b. If discharge is observed, did it reach Surface Water? (If yes, notify DWQ)
c. If discharge is observed, what is the estimated flow in gel/min?
d. Does discharge bypass a lagoon system? (If yes, notify DWQ)
3. Is there evidence of past discharge from any part of the operation?
4. Were there any adverse impacts to the waters of the State other than from a discharge?
5. Does any part of the waste management system (other than lagoons/holding ponds) require
maintenance/improvement?
6. Is facility not in compliance with any applicable setback criteria in effect at the time of design?
7. Did the facility fail to have a certified operator in responsible charge?
7/25/97
❑ Yes 14 No
❑ Yes (XNo
Mtk
❑ Yes kA No
❑ Yes VNo
❑ Yes CR�No
❑ Yes XNo
❑ Yes ' 4M
❑ Yes % No

Facility Number: � —E-3-3
8. Are there lagoons or storage ponds on site which need to be properly closed? ❑ Yes XNo
Structures (Lagoons.II91ding Ponds, Flush Pits, etc.)
9. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Yes ONO
Structure I Structure 2 Structure 3 Structure 4 Structure 5
Structure 6
Identifier:
Freeboard(tt): ....... d...�...t.�...............................................................................................................................................................................................
10.
Is seepage observed from any of the structures?
❑ Yes
JK No
11.
Is erosion, or any other threats to the integrity of any of the structures observed?
❑ Yes
ONO
12.
Do any of the structures need maintenance/improvement?
❑ Yes
C�No
(If any of questions 9-12 was answered yes, and the situation poses
an immediate public health or environmental threat, notify DWQ)
13.
Downy of the structures lack adequate minimum or maximum liquid level markers?
❑ Yes
No
Waste Application
14.
Is there physical evidence of over application?
❑ Yes
No
(If in excess of WMP, or runoff entering waters of the State, notify DWQ)
15.
Crop type ................(... ..�..�.....---.......
s.. � 1....[,.. ......................................................................................
...........----
16.
Do the receiving crops differ with those designated in the Animal Waste Management Plan (AWMP)?
❑ Yes
No
17.
Does the facility have a lack of adequate acreage for land application?
❑ Yes
No
18.
Does the receiving crop need improvement?
WYes
4�No;,�
19.
Is there a lack of available waste application equipment?
❑ Yes
tallo
20.
Does facility require a follow-up visit by same agency?
❑ Yes
allo
21.
Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
ElYes
[ No
22. Does record keeping need improvement? ❑ Yes Wo
For Certified or Permitted Facilities Only
23. Does the facility fail to have a copy of the Animal Waste Management Plan readily available? ❑ Yes No
24. Were any additional problems noted which cause noncompliance of the Certified AWMP? ❑ Yes No
25. Were.any additional problems noted which cause noncompliance of the Permit? ❑ Yes '(No
0• No.violations•oe deficiencies:were-noted during this:visit:- :Yo_ diiill- ireceiwe,itv-fdrth:er
- . • cbrrespu>�idepce atiout this;visit:• :::. . : ; .:.:: .:.:.... :. . :...
Ig) dew x3 rY 9t� — � -���, ��IY
inea� V@ &-,Fry
k ,o��..
��-e. ; �W.w` (��,� �;-.��` ��-.� �e.�-�� , X��p �► �Q� wad.. .
7/25/97
Reviewer/Inspector Name
Reviewer/Inspector Signature: '*__�(_X Date: [ I r 1-)_L1 119

State of North Carolina
Department of Environment
and Natural Resources
Division of Water Quality
James B. Hunt, Jr., Governor
Wayne McDevitt, Secretary
A. Preston Howard, Jr., P.E., Director
June 23, 1998
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
1C�lic ae t
Triple H Farms
659 Kinsey Mill Rd
Mt. Olive NC 28365
Farm Number: 31 - 833
Dear Michael Hill:
1 • •
NCDENR
NORTH CAROLINA DEPARTMENT OF
ENVIRONMENT AND NATURAL RESOURCES
You are hereby notified that Triple H Farms, in accordance with G.S. 143-215.1OC, must apply
for coverage under an Animal Waste Operation General Permit. Upon receipt of this letter, your farm
has siz 60 days to submit the attached application and all supporting documentatiori. In accordance
with Chapter 626 of 1995 Session Laws (Regular Session 1996), Section 19(c)(2), any owner or
operator who fails to submit an application by the date specified by the Department SHALL NOT
OPERATE the animal waste system after the specified date. Your application must be returned
within sixty (60) days of receipt of this letter. Failure to submit the application as required may also
subject your facility to a civil penalty and other enforcement actions for each day the facility is operated
following the due date of the application.
The attached application has been partially completed using information listed in your Animal
Waste Management Plan Certification Form. If any of the general or operation information listed is
incorrect please make corrections as noted on the application before returning the application package.
The signed original application, one copy of the signed application, two copies of a general location
map, and two copies of the Certified Animal Waste Management Plan must be returned to complete the
application package. The completed package should be sent to the following address:
North Carolina Division of Water Quality
Water Quality Section
Non -Discharge Permitting Unit
Post Office Box 29535
Raleigh, NC 27626-0535
If you have any questions concerning this letter, please call at [phone] extension or Dave
Holsinger with the Wilmington Regional Office at [phone].
Sincerely,
.{,- A. Preston Howard, Jr., P.E.
cc: Permit File (w/o encl.)
Wilmington Regional Office (w/o encl.)
P.O. Box 29535, Raleigh, North Carolina 27626-0535 Telephone [phone] FAX [phone]
An Equal Opportunity Affirmative Action Employer 50% recycled/ 10% post -consumer paper

❑ Division of Soil and Water Conservation ❑ Other Agency
® Division of Water Quality
Routine 0 Complaint 0 Follovv-ue of DIVQ ins action 0 Follow-up of 1?SWC review 0 Other
Date of Inspection } i
Facility Number 3 Time of Inspection � 24 hr. (hh:mm)
© Registered 1% Certified [3 Applied for Permit 0 Permitted JE3 Not t} eratk►nal Date Last Operated:
Farm Name `f +lt County:`
Owner Name: ........ I•&.0 al ...... 14.1.L1.......................................................................... Phone No:..Lr� }.... r.3 .'. 1tP .....L4.m!+:A...............
Facility Contact: ...... ki.l:�kQ L-1.......... -?..,` i.�......................... Title . ....... 4nt.,,.,................................... Phone No: ,�.�irrt� a�'�.`� .� .�............
Mailing Address: ......
�R.'............................................ .................................................... Integrator:., �- r......M�,SI ......4�.�i.V. .;....C.............................. �1�./ata.....
OnsiteRepresentative: ......k-L- f0'A.....� .t,.�l....... g �...
I......�.............................................
Certified Operator;.......... .[;........... 4.►.11............... ......................................... Operator Certification Number:...................................
Location of Farm:
14.......... 0. ..t,ori ....... rx...1... . �.... u-cy.s...tN.....Ax\......
�.,...
rs5......�nr.rti. ........5K.10.R.,.r..»S...1n�S.ax\....5a.L.'
.s. �Llk�.
r++asr. rya S�......
Latitude =0 4 ®11 Longitude [�• ®° ®11
Design Current
„
": Design ' @urreaty i Design Current;
Swine ,�
Capacity Population
F•oultry
Capacity Population ~ CattleCaPacity PopulatKon ,
❑ Wean to Feeder
JEJ Layer I
I ':]❑ Dairy
Feeder to Finish
10 Non -Layer
❑ Non-Dairy
EI❑
�
Farrow to Wean
= x
-
❑ Farrow to Feeder
❑ Other
'a..'.�
❑ Farrow to Finish
$, Total Di sign Capacityk
❑ Gilts
"
BDars
[IT
ota1.SSLW
Number of tagoons ! Holding=Ponds
Subsurface Drains Present ❑ Lagoon Area
M Spray Field Area
a
❑ No Liquid Waste Management System'
s ,g
,a ,"" ` �a
General
1. Are there any buffers that need maintenance/improvement?
WYes
❑ No
2. Is any discharge observed from any part of the operation?
❑ Yes
MNo
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made?
❑ Yes
CgNo
b. If discharge is observed, did it reach Surface Water? (if yes, notify DWQ)
❑ Yes
[4 No
c. If discharge is observed, what is the estimated flow in gal/min?
•d. Does discharge bypass a lagoon system? (If yes, notify DWQ)
❑ Yes
® No
3. Is there evidence of past discharge from any part of the operation?
❑ Yes
JO No
4. • Were there any adverse impacts to the waters of the State other than from a discharge?
❑ Yes.
I& No
5. Does any part of the waste management system (other than lagoons/holding ponds) require
❑ Yes
91 No
maintenance/improvement?
6. Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
MNo
7. Did the facility fail to have a certified operator in responsible charge?
❑ Yes
i9 No
7/25/97
Continued on Back

Facility Number:
8. Are there lagoons or storage ponds on site which need to be properly closed?
❑ Yes
gj No
Structures (Lapoons.1-folding fonds Flush Pits etc.
9. Is storage capacity (freeboard plus storm storage) less than adequate?
❑ Yes
No
Structure l Structure 2 Structure 3 Structure 4 Structure 5
Structure
6
Identifier:
Freeboard (ft): ............................................................... ................................... ........................ ............ ...................... ..............
.
10. Is seepage observed from any of the structures?
❑ Yes
IN No
It. is erosion, or any other threats to the integrity of any of the structures observed?
❑ Yes
® No
12. Do any of the structures need maintenance/improvement?
N Yes
❑ No
(If any of questions 9-12 was answered yes, and the situation poses
an immediate public health or environmental threat, notify DWQ)
13. Do any of the structures lack adequate minimum or maximum liquid level markers?
❑ Yes
No
Waste Application
14. Is there physical evidence of over application?
❑ Yes
No
(If in excess of WMP, or runoff entering waters of the State, notify DWQ)l
15. Crop type ...............i....................C4.rn........l Sk............. .-S-Y.6-eAr..........................................................................
16. Do the receiving crops differ with those designated in the Animal Waste Management Plan (AWMP)?
❑ Yes
U,No
17. Does the facility have a lack of adequate acreage for land application?
❑ Yes
Ij No
18. Does the receiving crop need improvement?
PQ Yes
,&No
19. Is there a lack of available waste application equipment?
❑ Yes
® No
20. Does facility require a follow-up visit by same agency?
❑ Yes
JS No
21. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes
9No
22. Does record keeping need improvement?
Q Yes
❑ No
For Certified or Permitted Facilities Only,
23. Does the facility fail to have a copy of the Animal Waste Management Plan readily available? $Yes lg No
24. Were any additional problems noted which cause noncompliance of the Certified AWMP? ❑ Yes IN No
25. Were any additional problems noted which cause noncompliance of the Permit? ❑ Yes � No
No.violations or. deficieitcies.were noted -during this:visit.-:Yoit:rvill ikeive'nolfiirther .,
ctirrespondepce d4out-this'.visit:::....:.
� s0hx"�2 was � @ x •'. � '4ti � hL .. N �' x` p l:�4'°�Y.Y °°ff-
Go tumen#s (refer to question #) ]Explatn3any YES answers and/or anj! recorntendations or�anylotl er comments ;t :z
Use drawings facthty to better:explaftl �F
of smtuatttins.a(use additional pages as necessury��
E �,' i e
lL. b ►- d�u� wall Er ao,. ��v�c� �a w►alutd. 6, oxca an pJV d.kt Whll S�noutd b� v�eeeC e�,
ar
l�• GOA{ � �OtYYhJ�O- GV� }-cvYAC e ta
S�np`v�C/ a i 1_ PYovej.
1�.O OL4 S" 41OUId �3a it, �6,. S�tI -ECO41 Sln4vii a. VLO b Hl l
rcllht�¢r per¢} �1 Clt� mv&m er �� 00.R n+ `rr1�a �eSS►1
$th- �oc.�anGe .,►�, Or t �} 0. aan
3 . �,tr'�=.�i cc-�or•- �0rm 5+�ad�� 4i� �� W �� Ccr� t� � �t0►-•
7/25/97
„�..�.:�._ yam- ---� ��
Reviewer/Inspector Name s
Reviewer/Inspector Signature: [late: S