310365_INSPECTIONS_20171231

NORTH CAROLINA
Department of Environmental Qual

(Type of Visit: Q'Compliance Inspection U Operation Review Q Structure Evaluation Q Technical Assistance I
Reason for Visit: 0 Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: \ Aval Time: ( ;.fir✓ Departure Time: r' a County: (h ^ Region:&)t
r ,~
Farm Name: ``t r �t~�'�1 Owner Email:
Owner Name: ()avt Phone:
Mailing Address:
Physical Address:
Facility Contact: Z� o .r__ S O f[ Title: Phone:
f `� "'to
Ousite Representative: { Integrator: �vtr,�
Certified Operator: l f Certification Number: If 23; �
Back-up Operator:
Location of Farm:
Latitude:
Certification Number:
Longitude:
Swine
Design Current
C►►opacity Pop.
Design Current
Wet Poultry Capacity Pop.
Cattle
Design Current
Capacity Pop.
Wean to Finish
Layer
Dairy Cow
Wean to Feeder
]Non
-Layer
Dairy Calf
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
DesignI UG'U'r—g—H t=
Dty P,auIt . Ca aci P,a ,
Layers
Dairy Heifer
D Cow
Non -Dairy
Beef Stocker
Gilts
Non -La ers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Other
Other
Turkeys
Turke Poults
Other
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure . ❑ Application Field ❑ Other:
❑ Yes '�o ❑ 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 [a --NA ❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWR) ❑ Yes ❑ No E N_A ❑ NE
2. Is there evidence of a past discharge from any part of the operation? ❑ Yes [3-No ❑ NA ❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters ❑ Yes 0 No ❑ NA ❑ NE
of the State other than from a discharge?
Page I of 3 21412015 Continued

Facility Number: - _ f �- _ Date of Inspection: Atj7,
Waste Collection & Treatment
Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
[9-N'T--❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No
❑-I A
❑ NE
Structure 1 Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): 12�
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
[,_'�No
0 NA
❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a
❑ Yes
[] No
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat,
notify DWR
7. Do any of the structures need maintenance or improvement?
❑ Yes
[] No
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
E],1qo
❑ 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
[3'—No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
0—No
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes [ T 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): C
13. Soil Type(s): N p 6 a'�
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
[3No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
[allo
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
E] No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
[fNo
❑ NA
❑ NE
Re uired Records & Documents
�No
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
EfNo
❑ 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 [a No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? 0 Yes �No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes EJ No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑NA ONE
❑ NA ❑ NE
Page 2 of 3 21412015 Continued

Facility Number: - Date of Inspection:
2,4. 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
❑ Yes
❑ No
❑ NA
❑ NE
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
❑ No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
❑ Yes
❑ No
❑ NA
❑ NI
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Yes
❑ No
❑ NA
❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
❑ No
❑ NA
❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
❑ No
❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
❑ No
❑ NA
❑ NE
Comments (refer; to question ft Explain anyYE&answers-and/or any additional recommendations or any other comments.
Use drawings of facility to:better explain situations (use additional pages as necessary}.
zp( -z - t' &° 'Li, t I
Reviewer/Inspector Name:
e
Reviewerllnspector Signature: L
Page 3 of 3
C. 1(.0-- 306_ 6 ss�
Phone: 1 j oJ" 3j �t �,'---
l
Date:
2141201 S

//
Type of Visit: (D CorMpliance Inspection O Operatoo eview Q Structure Evaluation O Technical Assistance I
Reason for Visit: Routine O Comps ollow-up O Referral O Emergency O Other Q Denied Access
Date of Visit: Arrival Time: Departure Time: County: Region:
Farm Name:
Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: Title:
Onsite Representative: R tj 0 `ur n A r 1t
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Phone:
Integrator:
Certification Number: Z y p
Certification Number:
Longitude:
Swine
Wean to Finish
Deslgn Current
Capacity Pop.
I
Design Current
Wet Poultry Capacity Pop.
I Layer I
INon-Layer I
Design Current
C*attle C►►opacity Pop.
Dairy Cow
Dairy Calf
W n'to Feeder
I
eeder to Finish
24Lk
Dairy Heifer
Farrow to Wean
Design Current
D , P,oult , -a aci P,o
Lavers
Dry Cow
Farrow to Feeder
Farrow to Finish
Non -Dairy
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
01
Other
Other
Turkeys
Turkey Poults
Other
Discharges and Stream Impacts
I . Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
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 ❑`K�o❑ NA ❑ NE
❑ Yes ❑ No
❑ Yes ❑ No
❑NA ONE
❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes [� No ❑ NA ❑ NE
[—]Yes No ❑ NA ❑ NE
Page I of 3
21412015 Continued

Facili dumber: Date of Inspection: 71
op y
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
rNo
❑ 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
EJ No
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health
or environmental threat, notify DWR
7. Do any of the structures need maintenance or improvement?
❑ Yes
No
[—]'NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
[:]Yes
No
❑ NA
❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require
❑ Yes
Q No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
ZfNo
❑ NA
❑ NE
maintenance or im rovemen0
P
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?
15. Does the receiving crop and/or land application site need improvement?
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
the appropriate box.
❑ WUP ❑ Checklists ❑ Design ❑ Maps ❑ Lease Agreements
❑ Yes
EJ No
❑ NA
❑ NE
❑ Yes
❑'1 0
❑ NA
❑ NE
❑ Yes
EJ'No
❑ NA
❑ NE
[—]Yes L'J c ❑ NA ❑ NE
[:]Yes F]"N-o ❑ NA ❑ NE
❑ Yes [ N ❑ NA ❑ NE
❑ Yes WNo ❑ NA ❑ NE
❑ Oth
21. Does record keeping need improvement? If yes, check the appropriate box ��SoilAnalysis
Yes o ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Waste Transfers ❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V Rainfall Inspections Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes o y❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes >1 "" ❑ NA ❑ NE
Page 2 of 3 21412015 Continued

Facility dumber: - Date of Inspection: 7 t
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 No ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes ❑ No �NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes No ❑ NA ❑ NE
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern? ❑ Yes 6 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 0 No ❑ NA ❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Yes
No
❑ NA
❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
No
❑ NA
❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
allo
❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
0 Yes
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 sitiiah©as (use addittonal.pages'as necessary):
Reviewer/Inspector Name:
c.
o
(—Pena-J
15
Phone: l 0 7fG 73 0
Reviewer/Inspector Signature:
Page 3 of 3
Date: �T Z
21412015

i rpc ui v ibis: L! %.qJ111p112tuce luspecuuu v vperauuu rteriew V aMuciure c raivauUu L! i ecun+cM JAMIStauce
Reason for Visit: iceyeontine 0 Complaint, 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: j j�%1j� Arrival Time: Departure Time: 1) County: Region:
Farm Name: Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: / Title:
Onsite Representative: I ' P mot/ 64t r-A �r [� Integrator:
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Phone:
Certification Number:
Certification Number:
Longitude:
Design C►urrent Design Current
Swiue Capacity op. Wet Poultry Capacity Pop.
Wean to Finish I I Layer
Design
Cattle Capacity
Dairy Cow
Current
Pop.
" to Feeder
I
jNon-Layer
I
Dairy Calf
eeder to Finish Z-q u it
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Z 3 9
Design Current
D . Poultry Ca aei P,o r
Layers
Dairy Heifer
Dry Cow
Non -Dairy
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Turke s
Turke Points
Other
Beef Brood Cow
Other
Oth er
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
ff&o ❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
[] Yes
❑ No ❑ NA
❑ NE
b. Did the discharge reach waters of the State? (if yes, notify DWR)
❑ Yes
❑ No ❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWR)
❑ Yes
❑ NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑Yes
2�0r_i
NA
❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters
❑ Yes
[—]No ❑ NA
❑ NE
of the State other than from a discharge?
Page 1 of 3 21412015 Continued

Facili Number: 51 - r Date of Inspection: I Z I7
Waste Collection & Treatment
4. Is storage capacity (structural plus stone 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): 3 _
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 ❑ o ❑ 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 environ ent real, notify DWR
7. Do any of the structures need maintenance or improvement? es No NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes No ❑ NA ❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes No ❑ NA ❑ NE
maintenance or improvement?
Waste Atlklication
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes EfNo
❑ 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 N
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
Yes No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes 0 No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
No NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
10 ❑ NA
❑ NE
the appropriate box.
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements
❑Other:
21. Does record keeping need improvement? If yes, check=ttppropriate box below
�Ys
❑ No ❑ NA
❑ NE
❑ Waste Application ❑ Weekly Freeboard e Analysis oil 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
ErNo ❑ NA
❑ NE,-"�
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes ❑ No ❑ NA
Page 2 of 3 21412015 Continued

Facili Number: - f Tp jDate of inspection: j
24-Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
Ej< NA
❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check
❑ Yes
o ❑ NA
❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail 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
B❑
❑ No O'FiA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
❑Ko ❑ 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
E rNo[:l NA
ONE
If yes, contact a regional Air Quality representative immediately.
Co❑
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
❑ Yes
NA
❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
op
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Yes
o ❑ NA
❑ 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?
es
rNo,❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
P rNo❑ NA
❑ NE
Comments (refiCi�to'.question #) Expliii f nyoYES;answers;a yr any�lailditional recommendati©ris or any other comments .s 3e�
��� ty �t..: N
UseQ rawin of�faciliito better. e`zplaid situation! Curse ad[litwnal pages as necessary)
rd
/ih �Pi f C� r �9 �^� t. - o l✓n 2 /s O T� T S / �+SPP c' o '
VC
('
l a C _e 5 d 1 , re C(ct C P_ e r'o 5.Q� �- �c s� �`
e\ L 4^ Q t-r,,,c�' S.
So
/ S
C p/t; r. fC/ o n pr {eG._py1g
e- 3 i,,e 6k el Ll C-C C." r "r-'-_ 1- d '\� C lit ^-., . -r t-- I
`-f^45 9eCwarlr c W ! ' 990� i�'r [3 dQf 5 6CforeIfa j'tCr�
9 _f c_ j P f / of 1-on be 4" AU 1'01�
Reviewer/Inspector Name: aV I (� 3Sf VL . Phone: 0 -7`�
Reviewer/Inspector Signature: Date: ? 7
Page 3 of 3 21412015

L
Type of Visit: UCom nee Inspection U Operation Review Q Structure Evaluation U Technical Assistance
Reason for Visit: er 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 Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact:
Title:
Onsite Representative:
^ y
IlG/�P �, ���
Integrator:
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Phone:
Certification Number:
Certification Number:
Longitude:
4_f�V>
Design Current Design Current
Swine Capacity Pop. Wet Poultry Capacity Pop.
Wean to Finish ILayer
Cattle
Dairy Cow
Design Current
Capacity Pop.
Wean to Feeder
I iNon-Layer
I El
Dairy Calf
Feeder to Finish
Dairy Heifer
Farrow to Wean
Farrow to Feeder
Design Current
Dr, P,oult , Ca aci P,o P.
Dry Cow
Non -Da'
Farrow to Finish
Layers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turke s
Other Turkey Poults
Other I Other
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation? ❑ Yes ❑ 1fi o ❑ NA ❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made? ❑ Yes ❑ No ❑ NA ❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWR) ❑ Yes ❑ No ❑ NA ❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWR)
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 o ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
Page I of 3 21412015 Continued

[Facility Number: - Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes ❑ 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): 4 Z_
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 40 ❑ NA ❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWR
7. Do any of the structures need maintenance or improvement? ❑ Yes No [] NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes EI 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 U No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes [,-,rNo ❑ 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 ❑ No ❑ NA CjRE
IS. Does the receiving crop and/or land application site need improvement? ❑ Yes ❑ No ❑ NA [nNE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes ❑ No ❑ NA �F
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
❑ No
[DNA
[rNE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
❑ No
❑ NA
NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
❑ No
❑ NA
[rNE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
❑ No
❑ NA
the appropriate box.
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. 0 Yes ❑ No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? [:]Yes ❑ No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes ❑ No
❑ NA NE
❑ Weather Code
❑ Sludge Survey
❑NA ONE
❑ NA NE
Page 2 of 3 21412015 Continued

Facili Number: - b �' Date of Inspection:__
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes [:]No ❑ NA n.PdE�
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes ❑ No ❑ NA T�Pd
the appropriate box(es) below. TT
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge? [:]Yes [2 <o ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? [:]Yes ❑ No NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
No
❑ NA
❑ NE
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
❑ Yes
[] No
❑ NA
[?Iq'E
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tite drains exist at the facility? If yes, check the appropriate box below.
❑ Yes
❑ No
❑ NA
P "`E
[3 Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
,E]_No
❑ NA
❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
❑" o
❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
ED-K-o
❑ NA
❑ NE
_ ` k I S(2CG
Reviewer/Inspector Name:
Reviewerllnspector Signature:
Page 3 of 3
Phone: `
Date: r��Q
21412015

Type of Visit: ompliance Inspection Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: 01doutine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: Departure Time: � 9� • County: Region"_ r
Farm Name:
Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: Title:
Onsite Representative: J d" Q S
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Phone:
Integrator: M
Certification Number: ' (p
Certification Number:
Longitude:
Design Current
Swine Capacity Pop.
Wean to Finish
Design Current
Wet PoultaS' Capacity Pap.
Layer
Design Current
Cat#le Capacity Pop.
Dairy Cow
Wean to Feeder
I
INon-Lyer I
Dairy Calf
Dairy Heifer
Dry Cow
Non -Dairy
Beef Stocker
Feeder to Finish t4
Design Current
D P■oul Ca aci_ P,o
I Layers
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
I
Non -Layers
HBeef
Beef Feeder
Boars
Pullets
Tufke S
Turke Pouets
Other
BroodHCow
Wither
Other =
Discharees and Stream Imoacts
1. is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWR)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWR)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
❑ Yes No ❑ NA ❑ NE
❑ Yes [,] No ❑ NA ❑ NE
❑ Yes [—]No ❑ NA ❑ NE
❑ Yes [:]No
[—]Yes
gNo
Yes
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Page I of 3 21412014 Continued

Facili Number: - Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
No
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No
❑ 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
❑1'Zo—
❑ 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 envEr mental threat, notify DWR
7. Do any of the structures need maintenance or improvement? Yes ❑ No ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes No ❑ NA ❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes ff o ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes �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? ❑ Ye 0 No ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? Yes ❑ No ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes El '�o ❑ NA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
Reuuired Records & Documents
❑ Yes 2 1Vc . ❑ NA ❑ NE
❑ Yes �Zo ❑ NA ❑ NE
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes BNo ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes EYNo ❑ NA ❑ NE
the appropriate box.
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes �No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes ONo
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes E51N
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
o ❑ NA ❑ NE
Page 2 of 3 21412015 Continued

FaciliNumber: jDate of Inspection: �-`
24. flid the facility fail to calibrate waste application equipment as required by the permit? es ❑ No ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check []Yes [TNo ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey [:]Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge? ❑ Yes No ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes ❑ No ffNA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes Ej--No ❑ NA ❑ NE
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
❑ No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
❑ Yes
E3"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
dNo
❑ 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
[f o
❑ NA
❑ NE
34, Does the facility require a follow-up visit by the same agency?
❑ Yes
WNo
❑ NA
❑ NE
Comments (refer to question #): Explain any YES answers and/or any additional recommendations or any:other. comments. n
Use drawings of facility to better explain situations fuse additional Dapzes as_necessarvl"`
7 p, �j L
�n
�Ck- lt%CCA JrA
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: VO P b 7? 0
Date: 3 C S
2/4/20 4

Type of Visit: 91campliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: Gr9outine 0 Complaint. 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: I M/ Arrival Time: Departure Time: County: Region: %7
Farm Name: Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: Title:
Onsite Representative: S P-U"S",
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Phone:
Integrator: I%V=
Certification Number:
Certification Number:
Longitude:
Swine
Wean to Finish
Design
Capacity
Current Design Current
Pop. Wet Poultry Capacity Pop.
Layer
Cattle
Dairy Cow
Design Current
Capacity Pop.
Wean to Feeder
I
jNon-LMer
I
Dairy Calf
Feeder to Finish
De, P,oul
ILavers
Design Current
Ca aci P.o ,
Dairy Heifer
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Dry Cow
Non -Dairy
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Other
Other
Turke s
Turkey Poults
Other
Discharges and Stream Imnacts
1. Is any discharge observed from any part of the operation?
❑ Yes
❑ No
❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
❑ Yes
❑ No
❑ NA
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWR)
❑ Yes
❑ No
❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWR)
❑ Yes
❑ No
❑ NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
❑ No
❑ NA
❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters
[] Yes
❑ No
❑ NA
❑ NE
of the State other than from a discharge?
Page I of 3 2/4/2014 Cowin

Facility Number: -3 Date of Ins ection: a
Waste Collection & Treatment
4.,Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes �No [] NA ❑ NE
Struture 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'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 rfNo ❑ NA ❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWR
7. Do any of the structures need maintenance or improvement? [:]Yes Q No ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes TT[/] 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 P311�o
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes EfrNo
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below.
❑ Yes JZ"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 No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes eNo
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes 2'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 L2rNo
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes 0 No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes F,;rNo
❑ 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 12'Ro
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall []Stocking ❑ Crop Yield ❑ 120 Minute Inspections [:]Monthly and I" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes E fNo
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? (:]Yes @'No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 21412014 Continued

Facili Number: - Date of inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit.
❑ Yes
J�TNo
❑ NA ❑ NE
.�-
25 GIs the facility out of compliance with permit conditions related to sludge? If yes, check
❑ Yes
0'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
EyNo
❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
❑ Yes
,E�fr`No
❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
tNo
❑ 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
❑�To
❑ NA ❑ NE
If yes, contact a regional Air Quality representative immediately.
T
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
❑ Yes
[P,,&o
❑ 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
E!fNo
❑ NA ❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWIVIP?
El
vri
❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
No
NA ❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
�D No
❑ NA ❑ NE
Comments (refer to question # ): Explain any YES answers and/or any additional=`reco-mmendatious or -any other comments:' .
Usedrawingsof facility to better explain situations (use additional pages as necessary).
(12 41
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: f � j�
Date: //1 113 //-V
11412011

Reason for Visit: _jg�^ftoutine O Complaint O Follow-up Q Referral O Emergency O Other O Denied Access
Date of Visit: P Arrival Time: C' parture Time: County: Region:
Farm Name: Af Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: Title:
Onsite Representative: �.::r .Sr1 "
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Phone:
Integrator:
Certification Number: ,cs
Certification Number:
Longitude:
Design
Swine Capacity
Wean to Finish
Current
Pop.
Wet Poultry
Layer
Design
Capacity
Current
Pop.
Design Current
Cattle Capacity Pop.
Da' Cow
Wean to Feeder
Non -La er
Dai Calf
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Boars
Wither
Other
D , Pooult ,
La ers
Non -Layers
Pullets
Turke s
Turkey Poults
Other
Design
Ca aci_
Current
P.o ,
DairyHeifer
Cow
Non -Dairy
Beef Stocker
Beef Feeder
I Beef Brood Cow
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.,,,ZNo ❑ NA ❑ NE
❑ Yes �No
❑ Yes dNo
[:]Yes ff No
❑ Yes o
❑ Yes WNO
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑NA E]NE
[DNA ❑ NE
Page I of 3 21412011 Continued

[Facility Number: - Date of Inspection:
Waste Collection & Treatment
A4. 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 'ZNo
❑ NA
❑ NE
Structure 1 Structure 2 Structure 3 Structure 4
Identifier:
Structure 5 Structure 6
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes 5�>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 _�TNo
❑ 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 /El No
❑ NA
❑ NE
8. Do any of the structures 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
❑ Yes �' o
❑ NA
❑ NE
maintenance or improvement?
✓�
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes j "No
❑ NA
❑ NE
maintenance or improvement?
T
11. Is there evidence of incorrect land application? If yes, check the appropriate box below.
❑ Yes
❑ NA
❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals
.2rNo
(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 P110
❑ 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 J2-No
❑ NA
❑ NE
acres determination?
17. Does the facility tack adequate acreage for land application?
❑ Yes 2-No
❑ NA
❑ NE
18. Is there a tack of properly operating waste application equipment?
❑ Yes �Vo
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes',La'No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes e l 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 ;DNo
❑ 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 E57N[o
❑ NA
❑ NE
23..If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes P�qo
❑ NA
❑ NE
Page 2 of 3,
21412011 Continued

Facility Number: - Date of Inspection: "1
24. Did the facility fail to calibrate waste application equipment as required by the permi ❑ Yes rNo ❑ 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� /N'o ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ElYes � No ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
[] Yes [�2 No
0 NA ❑ NE
and report mortality rates that were higher than normal?
Z
29. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes r no
❑ NA ❑ NE
If yes, contact a regional Air Quality representative immediately.
T
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
❑ Yes )ZNo
❑ NA ❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Yes �No
❑ NA ❑ NE
El Application Field ❑ Lagoon/Storage Pond ❑ Other:
T
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes Ppo
❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes oNA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes yNo
❑ NA ❑ NE
Comments (refer to question ft Explain any YES answers and/or any additional recommendations.or any other comments.
Use drawings of facility to better explain situations (use additional pages as necessary).
,8 c 5u& /v a c :.
1 Z (wed
Gv )1Q rye &J CS
k'-'6l,J G. � ?
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
PtCC5 5"e SUI-V'AA3 Px�'
Or-, )2d1-v _ f r
0, K�' A
J-Atj j eq
Phone: —
Date:
4/2 Il

Type of Visit: Mompliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: /[_J Routo e 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
. _ i-A . ram,
Date of Visit:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
J
Time: Departure Time: County:: c c Region:
Facility Contact: Title:
Onsite Representative:
Certified Operator:
Owner Email:
Phone:
Phone:
Integrator:
Certification Number:
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
Design Current
Swine Capacity Pop.
Wet Poultry
Design
Capacity
C►urrent
Pop.
Design Current
Cattle Capacity Pop.
WeaZee
La er
airy Cow
Wea
Non-La er
airy Calf
Feed
Dai Heifer
Farro
l
r[fNon-Layers
Turke s
Turke PouIts
Other
Design
Ca acity
C►►urrent
Pao ,
D Cow
Non -Dairy
Beef Stocker
Beef Feeder
Beef Brood Cow
Farro
Farro
Gilts
Boars
Other
Other
Discharges and Stream ImD8et5
1. Is any discharge observed from any part of the operation? ❑ Yes 'P'No ❑ NA ❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other: C.
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 LONo ❑ NA ❑ NE
2. Is there evidence of a past discharge from any part of the operation? ❑ Yes o ❑ NA ❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters ❑ YesgNo ❑ NA ❑ NE
of the State other than from a discharge?
Page I of 3 21412011 Continued

Facility Number: M jDate of Inspection: Zj
Waste Collection'& Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes ,ffNo ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes T ["No ❑ NA ❑ NE
Struc7e 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 eNo ❑ 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 �lo ❑ NA ❑ NE
waste management or closure plan? TT
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes Z No ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
(not applicable to roofed pits, dry stacks, and/or wet stacks)
[:]Yes �TNo ❑ NA ❑ NE
9. Does any part of the waste management system other than the waste structures require ❑ Yes )2�No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need [:]Yes V(No ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes P No ❑ NA ❑ NE
❑ 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
ONo
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
,E:rNo
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
ZNo
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
ONo
❑ 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 ❑�4o ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes 1�rNo ❑ 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. [1040
Yes ❑ NA ❑ NE
El Waste Application ❑ Weekly Freeboard Waste Analysis ❑ Soil Analysis ❑]]Waste Transfers ❑ Weather Code
❑ Rainfall ❑Stocking ❑Crop Yield ❑ 120 inure Inspections ❑Monthly and 1" Rainfall Inspections ❑Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes A No ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes f No ❑ NA ❑ NE
Page 2 of 3 21412011 Continued

Facility Number: IDate of Inspection:
/
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
[ZNo ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? if yes, check
❑ Yes
oZfNo ❑ 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
VfN. ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
RfNo ❑ 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
PfNo ❑ 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
eN. ❑ 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
L�`No ❑ 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
o ❑ 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).
-' N c,� — d_
C'J 1 0-& W
�-n d-�.1C� �pgc�.fszr
cam-
� � /C 7 'P sue= e uvAi 1
/ Ckw-viAL adI
t (e
6aa j ,
Reviewer/Inspector Name: aet/t^ iE:4 uctK"7 e Phone: 110—/'7
Reviewer/Inspector Signature: ` Date: �J-
Page 3 of 3 A
l

'MY ision of Water Quality
Facilit 'Number �� 3 Division of Soil and'Water Conservation
• Q Other .Agency
Type of Visit,,.(DT—ompliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit 0 Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: Arrival Time: Q r t Departure Time: County: Region:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Owner Email:
Phone:
Facility Contact: Title: Phone No:
Onsite Representative: Y) Integrator:
Certified Operator: Operator Certi ,cation Number:
Back-up Operator:
Location of Farm:
Latitude: I--] o
Back-up Certification Number:
« Longitude: = o = ' 0
Design Current Design Current" Des, ie ACurrenY
Wet Poult
rySwine Capacity Population Capacity Population Cattle K Capacity 'Populahon
❑ Wean to Finish 10 Layer
❑ Wean to Feeder VIE] ❑Non -Layer
❑ Feeder to Finish
emu.
❑ Farrow to Wean 1]ry Poultry
❑ Farrow to Feeder
❑ Farrow to Finish ❑ Layers
❑ Gilts ` ❑ Non -Layers
El Boars El
wa I < ❑ Turkeys
Other : ; ❑T
urkey Poults
❑ Other _ ❑ Other
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
❑ Dairy Cow
❑ Dairy Calf
❑ Dairy Heifer
❑ Dry Cow
❑ Non -Dairy
❑ Beef Stocker
❑ Beef Feeder
❑ Beef Brood Cowf
Number. o1
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 Q'10o ❑ NA ❑ NE
❑ Yes ❑ No
❑ NA
❑ NE
❑ Yes ❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes ❑ No
❑ Yes �' o
❑ NA
❑ NE
❑ Yes,,QNo
❑ NA
❑ NE
Page 1 of 3 12128104 Continued

IjFacility-Numbe — Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes ONo ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
u Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
a p
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes '10 No ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed P P Y g El Yes �No'' ❑ NA ❑ NE
through a waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes 2fNo ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes PNo ❑ 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 ZNo ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes �3iVo ❑ NA ❑ NE
maintenance/improvement?
1 i. is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes O'No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ FAN > 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 J2'No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes ETNo
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
❑ Yes iE:fNo
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes D'f o
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes ❑ No
❑ NA
❑ NE
Com ents'(refer°to question 4): Exolain=any YES answers and/or any recommendations or any other comments
Use drawings of facility to: better, explain..situations (use:addtfional pages as necessary)
., a
Reviewer/inspector Name p, r Phone: (4^/
Reviewer/Inspector Signature: Date:'Z..?aZZ4:2� j
Page 2 of 3 12/2 /04 lCondnued

Facility Number: Date of Inspection VW1
Required Records & Documents
19. Did the facility fail to have 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 ❑ Design ❑Maps ❑Other
21.
Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes /PKb
❑ NA
❑ NE
ElWaste Application ElWeekly Freeboard ElWaste Analysis ElSoil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1"
Rain Inspections ❑
Weather Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes „a No
❑ NA
❑ NE
23.
if selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes E2f'fVo
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes ;Wo
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes ;l o
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes 2 No
❑ NA.
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes P<o
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes /"' o
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes .Z 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 o
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
_P
31.
Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes LI<o
❑ 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 �Ko
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes B'No
❑ NA
❑ NE
Additional Comments and/or Drawings:
f ? �
,y
6
VL L - g�
Page 3 of 3 12128104

Type of Visit jg compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visits Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: Arr�al ^im�: Departure Time: County: Rcgiolt�_22&r
Farm Name:
Owner Email:
Owner Name: I Phone:
Mailing Address:
Physical Address:
Facility Contact: Title:
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Phone No:
Integrator:
Operator Certification Number:
Back-up Certification Number:
Latitude: = 0 0 6 Longitude: = ° I=] = L[
g�M—=C-51ren—i
Wet Poultry
Capacity
Population
Design Cho
urrentSwine
Cattle Capacity Population
❑ Wean to Finish
❑ Layer
❑ Dairy Cow
❑ Wean to Feeder
10 Non -Layer I
I
❑ Dairy Calf
❑ Feeder to Finish
❑ Farrow to Wean
❑ Farrow to Feeder
Dry Poultry
❑ La ers
❑ Non -Layers
❑ Dairy Heifer
❑ Dry Cow
❑ Non -Dairy
❑ Farrow to Finish
❑ Beef Stocker
El Beef Feeder
811Gilts
Boars
Other
❑ Pullets
❑ Turke s
❑ Turkey Poults
❑ Beef Brood Co
of Structures:
❑ Other
❑ Other
INumber
Dischmes & 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 P"No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes '-;XNo
❑ Yes
ONo
❑ NA
❑ NE
❑ Yes J6 No ❑ NA ❑ NE
Page 1 of 3 12128104 Continued

Facility Number:_31 — Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes �JZNo ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes VTNo ❑ 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 VfNo ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes &No ❑ NA ❑ NE
through a waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes )] No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes KNo ❑ 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 Rj No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes �TNo ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes VNo ❑ 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
VNo
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
;KNo
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?[:] Yes
ONo
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
VrNo
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
�fNo
❑ NA
❑ NE
Reviewer/inspector Name Phone: �f
Reviewer/Inspector Signature: Date:
I -age 2 of 3 IL/L6/U4 uonnnuea

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

Division of Water Quality
Facility Number Division of Soil and Water Conservation
- - - _ Other Agency a
Type of Visit ACompliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit )6Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other Cl Denied Access
Date of Visit: Arrival Time: '� Departure Time: �g/ County: Region: r�O
Farm Name: Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: Title: Phone No:
Onsite Representative: ¢/I?�s� �_7,�4_ ?5"0AJ Integrator: Az-6
Certified Operator: Operator Certification Number:
Back-up Operator: Back-up Certification Number:
Location of Farm: Latitude: o = , 0 [t Longitude: = o = 6 =
gfi
Design Current ; Design Current Design Current;
=.Swuie: Capacity Population. "VVet`Ponitry Capacity Population Cattle Capacity Population
❑ Wean to Finish
❑ Wean to Feeder
Feeder to Finish
00
Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
Other:.
❑ Layer
I
❑ Non -Layer
+_
❑ La ers
❑ Non -La ers
❑ Pullets
❑ Turke s
❑ Turke Poults
❑ Other
❑ Daia Cow
❑ Daia Calf
❑ Dairy Heifer
❑ Da Cow
❑ Non -Dairy
❑ Beef Stocker
❑ Beef Feeder
❑ Beef Brood Cowl
Number of Structures �I
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 I of 3
❑ Yes '0 No ❑ NA ❑ NE
❑ Yes ❑ No
❑ NA
❑ NE
❑ Yes ❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes [--]No
❑ Yes No
❑ NA
❑ NE
10
❑ Yes �6No
❑ NA
❑ NE
12128104
Continued

Facility Number: — Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Structure 1 Structure 2 Structure 3 Structure 4
Identifier: i
Spillway?: /VQ
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
(ic/ 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
El Yes ❑ No
Structure 5
❑NA ❑NE
❑ NA ❑ NE
Structure 6
❑ Yes/,INo ❑ NA ❑ NE
❑ Yes ,11
No ❑ NA ❑ NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes No ❑ NA ❑ NE
(Not applicable to roofed pits, dry stacks and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes X
No [I NA El NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ YesNo ❑ 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 Outsi e of Area
12. Crop type(s) '!Sa ©llfa25 D
13. Soil type(s) �t/�
.
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes /Z(No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes //�No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
El � No
El
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes )Z"No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes O'No
❑ NA
❑ NE
Comments (refer to question #f): Explain any YES answers and/or any recommendations or any other comments
:Use drawings of facility to better explain situations. (use additional pages as necessary):
Reviewer/Inspector Name
Reviewer/Inspector Signature: _4 'QA�) 4r�y4 fJ� _ Date: 7(Z ZeL>y
Page 2 of 3 12128104 Continued

Facility Number: 5 Date of Inspection
Required Records & Documents /
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes 10No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes 9fNo ❑ NA ❑ NE
the appropriate box. ❑ WUP ❑ Checklists ❑ Design El Maps El Other /No
21. Does record keeping need improvement? If yes, check the appropriate box below. ElYes ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and I" Rain Inspections ❑ Weather Code
22. Did the facility fail to install and maintain a rain gauge?
❑ Yes
�No
❑ NA
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
❑ No
I NA
❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
X No
❑ NA
❑ NE
25. Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
51rNo
❑ NA
El NE
26. Did the facility fail to have an actively certified operator in charge?
El Yes
VNo
❑ NA
❑ NE
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
❑ No
PNA
❑ NE
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
YfNo
❑ NA
❑ NE
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
ONo
❑ 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
)23 No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
31. Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
&No
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
No
X,
❑ NA
❑ NE
33. Does facility require a follow-up visit by same agency?
❑ Yes
�TNo
❑ NA
❑ NE
Additional Comments and/or Drawings:
p F oo ���?zr. �', Cf{,gN��D ,�%n�� S"-zE,
(AJ e-t IVIZ p 1401 ,6,f— Z or✓eg_ ./ Zero,
©/j 14;h" 5 l [�6� SLD �iv ODJ� SozG
Page 3 of 3 12128104