310453_INSPECTIONS_20171231

Z Vn
NORTH CAROLINA
Department of Environmental Qua!

Type of Visit: Q CCopliance Inspection Q Operation Review Q Structure Evaluation Q Technical Assistance
Reason for Visit: Routine Q Complaint Q Follow-up Q Referral Q EmergencZ Q Other Q Denied Access
HSO
Date of Visit: Arrival Time: Departure Time: County- Region:
Farm Name: Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact:
Title:
Phone:
Onsite Representative: �(�1�i�T Spa Integrator:
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Phone:
Certification Number: 1$ b t
Certification Number:
Longitude:
Design Current
Swine Capacity Pop.
Wean to Finish
Wet Poultry
La er
Non -La er
Design
Capacity
I
Current
Pop.
Design Current
Cattle Capacity Pap.
Dairy Cow
Dairy Calf
Wean to Feeder
Feeder to Finish
Farrow to Wean
Design
Gurrent
Dairy Heifer
Dry Cow
Farrow to Feeder
D . Adult .
Ca acit
P,o .
Non -Dairy
Farrow to Finish
Gilts
Layers
Non -Layers
Beef Stocker
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turkeys
Other Turk e PouIts
tither Other
Discharges and Stream Impacts
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 ❑ NE
�] Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes ❑ NA ❑ NE
❑ Yes ❑ ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
Page 1 of 3 21412015 Continued

Facilit 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:4
Spillway?:
Designed Freeboard (in): r
Observed Freeboard (in): b
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 0 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 environme 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 2No ❑ 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 jNo ❑ NA ❑ NE
maintenance or improvement?
Waste Agnl€cation
14. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes No ❑ NA ❑ NE
maintenance or improvement? J
l 1. Is there evidence of incorrect land 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 141bs. ❑ 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
go
❑ 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
o
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
EjNco
❑ NA
❑ NE
Reiguired Records & Documents
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
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
VNo
❑ NA
❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis
❑ Waste Transfers
❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 124 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
YNo
❑ NA
❑ NE
Page 2 of 3
V4,2015 Continued

Facilit lAiurn6er: - Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes o ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes WNo ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a PCA 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 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 d�'o ❑ 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 ❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes FNo
❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency? ❑ Yes❑ NA ❑ NE
Coi 9diente;(refer to iiuestionr #) ,EXplain:Any YES. answers "and/or aay+additional`reconimenitations °oi aiiy"otFierl COM eats.
a; y ,,a 4 e,.s •.g�. �`&3 �.:s."stiraLx:.',r.p.3:"{�b
[Ise drawings'of3faeilitv,tn tietter exnlain�situations;fuse.addltional•nages,as necessarvl.x ,. € �� .,
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
.J af1 tj
Phone
Date: Y
21412015

U Division of Water Resources
.Facility Number - ® n Division of Soil and Water Conservation
y Q Other Agency
Type of Visit: WRoutine
pliance Inspection Operation Review Structure Evaluation ❑ Technical Assistance
Reason for Visit: Q Complaint Q Follow-up Q Referral Q Emergency Q Other Q Denied Access
Date of Visit: Arrival Time: ® Departure Time: ® County:.. Region:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact:
Onsite Representative:
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
Boars
Other
Other
Owner Email. -
Phone:
Title:
Latitude:
Phone:
Integrator:
Certification Number: 'tzpk_
Certification Number:
Design Current Design Current
Capacity Pop. Wet Poultry Capacity Pop.
ELayer
Design Current
,Dry Poultry Capacity Pop.
Layers
Non -Layers
Pallets
Turkeys
Turkev Poults
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 DW R)
2. 1s there evidence o F a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
Longitude:
Design Current
Cattle Capacity Pop.
Dairy Cow
Dairy Calf
Dairy Heifer
Dry Cow
.Non -Dairy
Beef Stocker
Beef Feeder
Beef Brood Cow
❑ Yes o ❑ NA ❑ N1
❑ Yes
❑ No
❑ NA
❑ NE
❑Yes
❑No
❑NA
[]NE
❑ Yes ❑ No [a NA ❑ NE
❑ Yes �o. ❑ NA ❑ NE
❑ Yes TD"No ❑ NA ONE
Page 1 of 3 21412015 Continued

Facility Number: - Date of Inspection:
Waste Collection & Treatment
/No
4. I`s 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 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
IdNo
❑ 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
o
gNo
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
❑ NA
❑ NE
(not applicable to rooted 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
ZNo
10. Are there any required buffers, setbacks, or compliance alternatives that need
[] Yes
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below.
❑ Yes
2(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
R�
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
[rNo
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
0 Yes
En No
[] NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
EYNo
❑ 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 ❑ 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 l" Rainfall Inspections
❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge?
❑ YesrNo
❑ NA
❑ NE
23. If selected, did the facility fail to install and maintain rairnbreakers on irrigation equipment?
❑ Yes
❑ NA
[] NE
Page 2 of 3
21412015 Continued

Facili Number: - Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes No ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes No ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey [] Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge? ❑ Yes o ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes Y.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
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 JO/No
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 En No
❑ Application Field ❑ Lagoon/storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
❑ Yes
❑ Yes
d�No
E/�No
EdNo
❑ NA ❑ NE
❑NA ❑NE
❑NA ❑NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Reviewer/Inspector Name: Phor : =13S
Reviewer/Inspector Signature: Date: to
Page 3 of 3 21412015

YO Division of Water Resources
Facility Number - ® Q Division of Soil and Water Conservation
11*1 Q Other Agency
Type of Visit: Ziance Inspection Operation Review Structure Evaluation Technical Assistance
Reason for Visit:utine Q Complaint Q Fallow -up Q Referral Q Emergency Q Other Q Denied Access
Date of Visit: Arrival Time:® Departure Time: County: Region:
Farm Name: Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact:
Phone:
Title:
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Design Current
Swine Capacity Pop.
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Boars
Other
Other
Latitude:
Phone:
Integrator:
Certification Number: 0 U
Certification Number:
Design Current
Wet Poultry Capacity Pop,
Layer
Non -La er
Design Current
Nan -La
Pullets
Poults
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made'?
b. Did the discharge reach waters of the State? (If yes, notify DWR)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWR)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge'?
Longitude:
Design Current
Cattle Capacity Pop.
Dairy Cow
Dairy Calf
Dairy Heifer
Dry Cow
Non-Dair
Beef Stocker
Beef Feeder
Beef Brood Cow
❑ Yes [/No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑Yes ❑ o []NA []NE
❑Yes N ❑NA ❑NE
❑ Yes VNo ❑ NA ❑ NE
Page I of3 21412015 Continued

Facili .Number: - Date of Inspection: 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 Stricture 4 Structure 5 Structure 6
Identifier: L�7[ i511
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):�
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes N❑ ❑ 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 0 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 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 V ❑ 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 UK ❑ 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 E�3/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
NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑Yes WN
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes 5/No
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes 1 'yo
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes [3 No
❑ NA
❑ NE
Reoulred Records & Documents
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 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 o
❑ NA
❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis
❑ Waste Transfers
❑ Weather
Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and l" Rainfall Inspections ElSludge 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 21412015 Continued

Facilit�,Number: jDate of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
o ❑ NA [] NE
25. is the facility out of compliance with permit conditions related to sludge? If yes, check
❑ Yes
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
WNo ❑ 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
M/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
b 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
Q No ❑ NA ❑ NE
33. Did the ReviewerlInspector fail to discuss review/inspection with an on -site representative?
❑Yes
Fit ❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
�(No ❑ NA ❑ NE
Comments (refer to question #) Explaln.any YES answers and/or. any additional reeom_ mendations or,any other'comments:::...
Use drawings' of !facility to better explain "situations (use additional.pa¢ea"as:'necessarv]. -_
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
jCl4)(i
Phon 796
Date:
Z/4 015

Type of Visit: C) Cornroutine
ante Inspection 0 Operation Review Q Structure Evaluation d Technical Assistance
Reason for Visit: Q Com faint O Follow-u 0 Referral Emergency Q 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: —To Integrator:
J7 .- Integrator:
Certified Operator:
Sack -up Operator:
Location of Farm:
Latitude:
Phone:
Certification Number:
Certification Number:
Longitude:
•
I IIIDesign Current
Design
Current
Design Current
Swine Capacity Pop.
Wet Poultry
Gapacity
Pop.
Cattle Eapaclty Pop,
Wean to Finish
La er
DairyCow
Wean to Feeder
Non -La er
Dal Calf
Feeder to Finish
DairyHeifer
Farrow to Wean
Design
Current
0 Cow
Farrow to Feeder
D . P,oult
Ca aci
P,o
Non -Dairy
Farrow to Finish
La ers
Beef Stocker
Gilts
on -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turkeys
Other
Turkey Puuets
Other
Other
Dischar es and Stream Im acts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify 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 1No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
[:]Yes ❑ o ❑ NA ❑ NE
❑ Yes Zo ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
Page 1 of 3 21412011 Continued

r
Facilit Number: Date of Inspection:
Waste Collection & Treatment
ZNo
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
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
1jNo
❑ 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 environmenta threat, notify DWQ
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
VNo
❑ 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
d/No
❑ NA
❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 101/n 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?
F!rYes
❑ No
❑ NA
❑ NE
16, Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
YNNo
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
E!fNo
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
ff No
❑ NA
❑ NE
Re uired Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
dN 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 o ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and l " Rainfall Inspections ❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? Yes No ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes Fz<o ❑ NA ❑ NE
Page 2 of 3 21412011 Continued

Facility Number: - Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permi ? ❑Yes N( ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? if yes, check [] Yes YNo ❑ 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
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?
❑ Yes 2No ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
❑ Yes dNo [DNA ❑ NE
❑ Yes
❑ Yes
❑ Yes
❑ Yes
❑ NA
❑ NA
❑ NA
(o
❑ NA
Comments (refer to question #): Explain any YES answers and/or any additional recommendations or any other comments.
Use drawines of facility to better exulain situations fuse additional nap -es as necessarvl.
WEC-D GJ FiTmoL, AIEEDED
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
❑ NE
❑ NE
❑ NF
❑ NE
Phon� J3 $
Date: 4 A y N
2V II

(Type of Visit: Q CC pliance Inspection Q Operation Review p Structure Evaluation 0 Technical Assistance
Reason for Visit: Routine Q Complaint Q Follow-up a Referral Q Emergency Q Other a Denied Access
Date of Visit: a Arrival Time: Departure Time: O County: jXJP. *J II II, Region:ll
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact:
Title:
Owner Email:
Phone:
Onsite Representative: '7TP").C,-T -ma_L .j C' Integrator:
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Phone:
Certification Number: l g4ej S
Certification Number:
Longitude:
Swine
Dgn
capacity
Eurrent
Pop.
Wet^Poultry
Design
Capacity
Current
Pop.
Design Gurrcnt
Cattle Capacity Pop.
Wean to Finish
La er
Dai Cow
Wean to Feeder
Nan-I,a er
Dairy Calf
Feeder to Finish
yy
Q
DairyHeifer
Farrow to Wean
Design
Current
D Cow
Non -Dairy
Farrow to Feeder
Dr. P,ouI r-
Layers
Ca aci
P,a P.
Farrow to Finish
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Beef Brood Cow
Soars
Pullets
Other
�iher
Turkeys
Turkey Puults
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 ZNo ❑ NA ❑ NE
❑ Yes
❑ No
[DNA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes E(p o [] NA ❑ NE
Yes Yo ❑ NA ❑ NE
Page 1 of 3 21412011 Continued

Facilit umber: 1 - 53 Date of Inspection: d ►
W ste Collection & Treatment
4. f s 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: Lit fsts" C
Spillway?:
Designed Freeboard (in): p
Observed Freeboard (in): O
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 environment 1 threat, notify OWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes [No ❑ NA ❑ NE
9. Do any of the structures lack adequate markers as required by the permit? ❑ Yes �f No ❑ NA ❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes �No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need [:]Yes �No ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? if yes, check the appropriate box below. ❑ Yes �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 EfNo ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes Ef. . o ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes gNo ❑ NA ❑ NE
acres detennination?
17. Does the facility lack adequate acreage for land application? ❑ Yes 60 ❑ NA ❑ NE
18, Is there a lack of properly operating waste application equipment? ❑ Yes 2�No ❑ NA ❑ NE
Required_ Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? [:]Yes 0 No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes CZ(No ❑ NA D 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 YNo ❑ NA ❑ NE
Page 2 of 3 21412011 Continued

Facili Number: I - 45a Date of Inspection:
24.ODid 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 g �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 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
❑ NA ❑ NE
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
No
❑ NA ❑ NE
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
[:]Yes No
❑ NA ❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
[:]Yes
ZNo
❑ NA ❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? [:]Yes ❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes L'J N ❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency? ❑ Yes o ❑ NA ❑ NE
Comments.(refer to questinnA#J: Explain.any"YES:answersiandlor'any additional re�ommendiatiaris or'iiiny other comments.
ilse'drawtn' °s of faciil ; tu`hetter,ex 'lain sit ations use;additli nali� a"es;a necessa .
( t; )
Reviewer/inspector Name: (j 1� r� Tt l� Phone:
Reviewer/Inspector Signature: Date:
Page 3 of 3 21412011

(Type of Visit: QF C
oHance Inspection U Operation Review Q Structure Evaluation Q Technical Assistance
Reason for Visit: Q Complaint ❑ Follow-up ❑ Referral ❑ Emergency ❑ Other ❑ Denied Access
Date of Visit: i a r r '�—r Arrival Time: ® Departure Time: ® County: 3..a& Region:
Farm Name: Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact:
Title:
Phone:
Onsite Representative: JA6L(ar S 1 E ka.1Lui Integrator:
Certified Operator -
Back -up Operator:
Location of Farm:
Latitude:
Phone:
Certification Number: ow
Certification Number:
Longitude:
Wean to Finish
I I
Layer I
jDairyCow
Wean to Feeder
I
INon-Layer I
Dairy Calf
Feeder to Finish
Dairy Heifer
Farrow to Wean
Design Current D Cow
Farrow to Feeder
P..oultr. Ea acit P,o on-DairyFarrow
ers beef Stocker
r
to Finish
Gilts
n-La ers
Beef Feeder
Boars
lets
Beef Brood Cow
Poults
Other
Discharges and Stream Impactsand Stream Impacts
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 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
❑
❑ NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
o
gNo
❑ 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 1 of 3 21412011 Continued

Facill Number: - Date of Ins ectlon:
Taste 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
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): y y
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 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 environm23No
1 threat, notify DWQ
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 2�No ❑ NA ❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require [:]Yes [No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes No ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. [:]Yes 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
U 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
ZNo
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ YesF�r<o
❑ NA
❑ NE
Re uired Records & Documents
No
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
E21�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
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 0 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 o ❑ NA ❑ NE
Page 2 of 3 2/4/2011 Continued

l+acili Number: - Date of Ins ection: r*
;4. 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 to 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 ZNo ❑ NA ❑ NE
Other issues
29, 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?
❑ Yes V/No ❑ NA ❑ NE
❑ Yes Ej No ❑ NA ❑ NE
❑ Yes M No ❑ NA ❑ NE
[:]Yes 10 ❑ NA ❑ NE
❑ Yes
D409
[:]Yes
Yes
Ld 'Y
No
❑
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Comments (refer to gvestlan:#): Explain any. YES�answers`.and/or.,any. additional€eecomniciidatians�or=anysother`connments
Use drarviites of facilit� to better;' laifi Ituations (use additional t tisesgasin ce sr
Reviewer/inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: (� Q
Date: sl 1 Y 17,
VV2011

E
f Visit CCoo Pliance Inspection Q Operation Review Q Structure Evaluation a Technical Assistance
n for Visit t! Routine Q Complaint Q Follow up Q Referral Q Emergency 0 Other ❑ Denied Access
(late of Visit: Arrival Time: ❑❑ Departure Time: County: Region:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact:
Onsite Representative:
Certified Operator: _,
Hack -up Operator:
Title:
Owner Email:
Phone:
Phone No:
Integrator:
Operator Certification Number:
Hack -up Certification Number:
Location of Farm: Latitude: 0 0 0 g = « Longitude: 0 ° 0 I = i{
Design Gurrent
Design Lurrent
Design Current
Swine Capacity Population
Wet Poultry Eapa�ityLpulation
Eattle Capacity Population
❑ Wean to Finish
JE1 Layer
I I❑
Dairy Cow
❑ Wean to Feeder
JE1 Non -Layer
I I
❑ Dairy Calf
Feeder to Finish CoZ.b
❑ Dairy Heifer
❑ Farrow to Wean
Dry Poultry
❑ Dry Cow
❑ Farrow to Feeder
❑ Non -Dairy
El Farrow to Finish
❑ La ers
❑ Beef Stacker
❑Gilts
❑ Non -Layers
El Beef Feeder
❑ Boars
El Pullets
❑ Beef Brood Cowl I
❑ Turkeys
Oth0
❑ Other
10 Turkey Poults
10 Other
Number of Structures:
Discharees & 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 n No ❑ NA ❑ NE
❑ Yes ❑ No
❑ NA
❑ NE
❑ Yes ❑ No
❑ NA
❑ NE
❑NA
El NE
❑Yes ❑N
❑ Yes
ElNA
ElNE
ElYes VN
❑ NA
❑ NE
Page 1 of 3 12128104 Continued

Tacility Number:
Date of Inspection �r
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: 0rJ
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): 3d
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 dNo ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
❑ Yes I.1f No
❑ Yes �No
❑ NA ❑ NE
❑ 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 c No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes �13 ❑ ❑ 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 [3Yes No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes 13 Nv ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes WNo ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > l0% 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
❑ 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 acre determination ?
❑ Yes
EX"No ❑ NA
❑ NE
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
.r;:;:..;i.'.':, .i.:.;.....f"::::.:f:'ts':;a�:;':...'�..#: ".
Comments (refer; tq question;#];' explain any YESanswers andlorxany'recomineAdatlansroranyother comments,
Us; �&awlrigs of facility to better explain situations.;[use;tiddiflonallpages as necessary}.`
PV` s°` i'x .,. ... •. is EL.
= : Phone: Ott aReviewerlInspector Name
erlInspector
Signature: Date: i
Page 2 of 3 12128104 Continued

Facility Number: Date of Inspection 3 1
l9enuired Records & Documents
19, Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes L/No ❑ NA ❑ NE
20, Does the facility fail to have all components of the CAWMP readily available? If yes, check 0 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
C?'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
No
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
C:rNo
❑ NA
❑ NE
24,
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
2No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
]�No
❑ NA
❑ NE
No
26,
Did the facility fail to have an actively certified operator in charge?
❑ Yes
Q
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
P�No
❑ NA
❑ NE
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
X0
❑ NA
❑ NE
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
VNo
Cl 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
ff 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
C?N'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
/o
❑ NA
❑ NE
33. Does facility require a follow-up visit by same agency?
❑ Yes
❑ No
❑ NA
❑ NE
iiddIti[inal Comments
apolor �raivinpps:
.. .. .. .. Rs ..... ... ... ..:.� e.: Cr':::....Y.y ........ �•: Z'Y. 14 a4-x�4'i��,. a�+t.ti��v�:t.Ss� � AL
Page 3 of 3 12128104

F.M11ty -Humber
F
peof Visit ,Ca piiance Inspection Q Operation Review Q Structure Evaluation Q Technical Assistance
ason for Visit �J Routine Q Complaint Q Follow up 0 Referral Q Emergency Q Other ❑ Denied Access
Date of Visit: Arrival Time: a d Departure Time; County: DR i-7L1-) Region:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Owner Email;
Phone:
Facility Contact: Title:
� j1
Onsi#eRepresentative:JJ .�, . lntegrator:
Certified Operator:
Back-up Operator:
Phone No:
Operator Certification Number:
Back-up Certification Number:
Location of Farm: Latitude: =]c E�:] ` 0" Longitude: Da = ' = «
Design: Current.
Design
Current
Design Current
Swine
o�
Capacity :_�f'$opulation .
Wet Poultry Capaclty
Populatiion
Cattle Capacity Popula#ion
❑ Wean to Finish
La er
❑ DairyCow
❑ Wean to Feeder
Non -La er
❑ Dai Calf
Feeder to Finish
p
❑ DairyHeifer
❑ Farrow to Wean
Dry Poultry
❑ D Cow
❑ Farrow to Feeder
❑ Non -Dairy
ElFarrow to Finish
Layers
El Beef Stocker
❑ Gilts
Nan -La ers
❑ Beef Feeder
❑ Boars
El Pullets
Co
❑ Turkeys
Other
❑ Other
❑ TurkeyPoults
❑ Qther
JJE1oBeefBrood
of Structures: 1
Discharges & Stream Impacts
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 DWQ)
❑ Yes
❑ No
❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
❑ Yes
No
❑ NA
ElNE
2. Is there evidence of a past discharge from any part of the operation?
ElYes
,❑
kT No
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
No
❑ NA
❑ NE
other than from a discharge?
Page 1 of 3
12/Z$104
Continued

r
Facility Number:3 t —
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: CAG_�J
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 ErNo ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
❑ Yes No ❑ NA ❑ NE
❑ Yes PNo ❑ NA ❑ NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental thrgat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes �I o ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes L 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 2f No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10, Are there any required bit ffers, setbacks, or compliance alternatives that need ❑ Yes dNo ❑ NA ❑ NE
maintenance/improvement?
11, Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes in No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 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 El No ❑ NA ❑ NE
15, Does the receiving crop and/or land application site need improvement? ❑ Yes �2rNo . ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ? ❑ Yes L o ❑ NA ❑ NE
17, Does the facility lack adequate acreage for land application? El Yes ❑ NA El
18. 1s there a lack of properly operating waste application equipment? El Yes � ❑ NA ❑ NE
Comments (refer to question #):: Explain any YES, answers aridlrir;any rerommend ations°or;any. other'commentsp :•. s,y"
Use drawings of facility to hetter.expiain situatirins: (use additional pages;as,necessary)• ° ` €' '• ; 4f��; `
x;s t
T
ReviewerllnspectorNorne
'f� '.i4i Sx''a"L :ate
7>1
�a 3 T= " "�' ��[t7 6
Phone:
,.s... �.
Reviewer/Inspector Signature:
Date: tar O
Page 2 of 3 l 12128104 Continued

�
r
Facility Number: 31 —�-} Date of Inspection
Reauired 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 [2 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
a
❑ NA
❑ NE
23,
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
NNo
❑ NA
❑ NE
24,
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
7No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
[Ao
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
[ No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification'?
❑ Yes
D4
❑ NA
❑ NE
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
❑ No'
❑ NA
❑ NE
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
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
P 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
,.,�
Ip 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
2 o
❑ NA
❑ NE
33. Does facility require a follow -tip visit by same agency?
❑ Yes
O No
❑ NA
❑ NE
Additional Comments and/or Drawin rs: f #: .<. 'F '°
.. , ,�
Page 3 of 3 12128104

Type of Visit 0 C mpilance Inspection Q Operation Review Q Structure Evaluation 0 Technical Assistance
Reason for Visit Routine 0 Complaint Q Follow up n Referral Q Emergency Q Other ❑ Denied Access
Date of Visit: Arrival 'Time: © Departure Time: County: Z)u;>Lz } Region:
Farm Name: Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact: Title:
Onsite Representative: �.IAPA j
Certified Operator:
Back-up Operator:
Phone:
Phone No:
Integrator:
Operator Certification Number:
Back-up Certification Number:
Location of Farm: Latitude: 0 e 0 ` = `I Longitude: 0 0 = t Q «
Swine W"_esign
�. s
�.
Capacity.
Current ❑esign Current Design Current
xa
Population Wet Poultry Capacity Population Cattle GapacIty Population
10 Layer ❑ Dairy Cow
10 Non -Layer I Dairy Calf
r td ❑ Dairy Heifer
Dr00 try ElD Cow
❑ Non -Dairy
❑ Layers
❑ Beef Stacker
❑ Non -Layers ❑ Beef Feeder
❑ Pullets
❑ ❑Beef Brood Cow
Turkeys
TurkeyPoults
❑Other Number of St►uctures:
❑
Wean to Finish
❑
Wean to Feeder
�(]
Feeder to Finish
14L(0
❑
Farrow to Wean
❑
Farrow to Feeder
❑
Farrow to Finish
❑
Gilts
❑
Boars
Other
❑ Giher
Discharges & Stream Impacts
1. is any discharge observed from any part of the operation?
❑ Yes
E4o
❑ 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
❑ No
❑ NA
❑ NE
2. 1s there evidence of a past discharge from any part of the operation?
❑ Yes
d
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
�/I No
❑ NA
❑ NE
other than from a discharge?
Page 1 of 3
12128104
Continued

Facility Numher: —40Date
of Inspection 2`1
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
[]Yes
N❑ ❑ 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: LA�_PJ
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): t
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
Pf No ❑ NA Cl 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 t eat, notify DWQ
7. Do any of the structures need maintenance or improvement`?
❑ Yes
o [INA ElNE
8. Do any of the stuctures lack adequate markers as required by the permit?
[IYes
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
ZNo ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
VNo ❑ NA ❑ NE
maintenance/improvement?
1 l . Is there evidence of incorrect application'? If yes, check the appropriate box below.
❑ Yes
2(No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Ln, etc.)
❑ PAN ❑ PAN > 10% or 10 1bs ❑ 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
❑ NA
[I NE
15. Does the receiving crop and/or land application site need improvement'?
❑ Yes
Zo
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?[] Yes
� ❑
❑ NA
El NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
20
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment'?
[I Yes
`No
❑ NA
❑ NE
Commentsh{refcr.tp. question.#):.::Explain ariy YFS Answers nndlarg�nycr((ecammendationsr,;.ur any other comments,
"�: L .. S � J 5 S• S: ws i 'Ai•%1���'�� ��R:�i� � N�
Use;dirawings itf facility to ttetter explain s�tuattons. (use'additianal pages as�necessary'. ��� • .��
"} i•}• 3- �¢ 'i'r n:.. ?r`C'FEri §"f,odir. rCd`�.:'r .7, `• ,
�t],� �TL-`tip 11 �q Sw fl G� r►�c�v E fl . {?i A+l D> O c 0 . to OOT AM
rx - T4 Cr A Qt tvATZ-10 rJJ.
Reviewer/Inspector Name i -- - - NakJ . t3c-u,. Phone q —
Reviewer/inspector Signature: Date:
r u91 vJ .� ..............»

Facility Number: — Date of Inspection
ReAuired Records & Documents
19. Did the facility fail to have Certificate oFCoverage & Permit readily available? ❑ Yes 2(No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available�Kher
es, check e Yes ❑ No ❑ NA ❑ NE
the appropirate box. ❑ WUP ❑ Checklists 6 ❑ Maps ❑ Design p
21. Does record keeping need improvemcnt? If yes, check the appropriate box below. ❑ Yes Id No ❑ NA ❑ NE
[:]Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis [:]Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute inspections ❑ Monthly and l" Rain Inspection�No
Weather Code
22. Did the facility fail to install and maintain a rain gauge? El Yes ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes o ❑ NA ❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes o
❑ 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 rail to have an actively certified operator in charge?
❑ Yes �No
❑ NA
❑ NE
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes I 4
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
El NA
El NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours andlor document
El Yes
,_,,(No
.Z No
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30.
At the time oFthe inspection did the facility pose an odor or air quality concern?
❑ Yes
2(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
2No
❑ NA
❑ NE
General Permit? (iel discharge, freeboard problems, over application)
32,
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
El Yes
�
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
L o
❑ NA
❑ NE
Additional Comments and/or Drawings:
Page 3 of 3 12128104

Facility Number. 1 �3
Division of Water Quality:'
Q Division of Soil and Water Conservation,
Q Other Agency
:°_.::
Type of Visit Q(7Routine
pliance Inspection O Operation Review Q Structure Evaluation Q Technical Assistance
Reason for Visit Q Complaint Q Follow up Q Referral 0 Emergency Q Other ❑ Denied Access
[late of Visit: , a>T Arrival Time: ItCd Departure 'rime: County: DVPL-tn] Region:
Farm Name:
Owner Name: _
Mailing Address:
Physical Address:
Facility Contact: Title:
Onsite Representative: JAILT 1fe01(ZN 5
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
Boars
Other
❑ Other
Owner Email:
Phone:
Phone No:
Integrator:
Operator Certification Number:
Back-up Certification Number:
Latitude: ='
=' ="
Longitude: = ° 0 =
Design Current Design . Current
Capacity Population Wet Poultry Capacity Population
❑ Layer
„1 .--- ❑ Nan -La er
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?
Cattle
Design Current
Capacity Population.-.
❑
Dairy Cow
❑
Dai Cali
❑
Dairy Heifer
0-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?
El Yes ICJNo El NA ❑NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
D<o
❑ NA
❑ NE
❑ Yes
; N
❑ NA
❑ NE
12128104 Continued

r;
j Facility ]Number: 31 — yS j Date of Inspection
y Waste Collection & 'Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes ICJ 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: t-14&aor-J
Spillway?;
Designed Freeboard (in):
Observed Freeboard (in): �J
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes [ No
❑ NA
❑ NE
Oe/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
❑ Yes ENo
❑ 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 t eat, 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 2fNo ❑ 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 Ayolication
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes ENo ❑ NA ❑ NE
m a i ntena tree/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below, ❑ Yes V(No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs ❑ Total Phosphorus ❑ Failure to Incorporate ManurelSludge 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
[l No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
[ No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?[] Yes
EfNo
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
o
Y�FN
El NA
[I NE
18. Is there a lack of properly operating waste application equipment?
El Yes
o
❑ NA
❑ NE
Comments (refer to question ft 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):
a4,) CAL=43&AIZ .1 tJitE❑f t-b l3E 00*�34;--, 30 OAYS
re
Reviewer/Inspector Name Jo i, f " Phone: y'1� �, --?v049,
Reviewer/Inspector Signature: Date:11,109
1 12128104 Continued

r,
l;•
t Facility Number: Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes L.Q No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes 0 No ❑ NA ❑ NE
the appropirate box. ❑ WUp ❑ Checklists ❑ Design ❑Maps El Other
21.
Does record keeping need improvement'! If yes, check the appropriate box below.
❑ Yes
EfNo
❑ 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
dNo
❑ NA
❑ NE
23,
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
El Yes
O No
❑ NA
❑ NE
24,
Did the facility fail to calibrate waste application equipment as required by the perm
LrJ/it? 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
Ell�1
No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
❑ No
WNA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
El Yes
,_dNo
E(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
Ef 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
El Yes
,..,%
L'( No
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32.
Did Reviewer/[nspector fail to discuss review/inspection with an on -site representative?
❑ Yes
E� o
❑ NA
ElNE
31
Does facility require a follow-up visit by same agency?
❑ Yes
No
❑ NA
❑ NE
Additional Comments and/or Drawings:
12128104

Division of Water Quality
Facility Number ({5'3 Q Division of Soil and Water Conservation.
0 Other Agency
Type of Visit '
pliance Inspection
Q Operation Review Q Structure Evaluation
Q Technical Assistance
Reason for Visit
,C.,00
V fautine Q Complaint
0 Follow up Q Referral Q Emergency
Q Other ❑ Denied Access
Date of Visit: I G 1 I (&:1 1 Arrival rime: Departure Time: County: ,7U2Lr - LkJ Region:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact:
Title:
Owner Email:
Phone:
Onsite Representative: SA0cc Integrator:
Certified Operator:
Back-up Operator:
Location of Farm:
Swine
Wean to Finish
Phone No:
Operator Certification Number:
Back-up Certification Number:
Latitude: = c 0 ` 0 " Longitude: = ° ❑ ` = "
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer
❑ Non-Layet
LI Feeder to Finish I1 ❑
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
Other
❑ Other
Dry Poultry
❑ La ers
❑ Non -Layers
❑ Pullcts
❑ 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?
Cattle
Design Current
Capacity Population:..
❑
Dairy Cow
❑
Dairy Calf
❑
Dairy Heifei
❑
Da Cow
❑
Non-DaiEX
❑
Beef Stacker
❑
Beef Feeder
❑
Beef Brood Co
b. Did the discharge reach waters of the State? (if yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
Number of Structures:
d. Does discharge bypass the waste management system? (if yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
❑ Yes 2 No ❑ NA ❑ NE
❑Yes ❑No El NA El NE
Cl Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑l No El NA El NE
El2 Yes No ❑ NA ❑ NE
❑ Yes M'No ❑ NA ❑ NE
12128104 Continued

Facility Number: 311 — L (g3 Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
,.,/
L� 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: LA ('-egor_�
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): 3s
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
ON.
❑ NA
❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
❑ Yes
OrNo
❑ 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 OWQ
7. Do any of the structures need maintenance or improvement? E Yes ❑ No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes E(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 strictures require El Yes l�l No ❑ NA ❑ NE
maintenance or improvement'?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes 0No ❑ NA ❑ NE
ma ntenance/improve ment?
11. Is there evidence of incorrect application'? if yes, check the appropriate box below. ❑ Yes �_,Ko ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Froxen Ground ❑ Heavy Metals (Cu, Zn, etc.)
[]PAN ❑ PAN > 10% or l0 lbs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drifi ❑ 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
L2 No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
Yes
❑ No
❑ NA
❑ NE
16. Did the Facility fail to secure and/or operate per the irrigation design or wettable acre determination?[] Yes
❑ No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
[:],N0
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
[�, o
❑ NA
❑ NE
{ Comments (refer to question #): Explain any YES answers and/or any recommendations or any other comments.
IUse drawings of facility to better explain situations. (use additional pages as necessary):
G R.ow-ni AA% DZi (A W iAUL S NEC- 4 L-LE-AQ L"G
I5.} W6EO CAN-r(LOL tik(--9�-q .
.! * as) Swv_ A s 31 - L4zcl �Skxpecxtaj
Reviewer/Inspector Name �� 1. Phone: _'73 29
Reviewer/Inspector Signature: Date:
...,,.cgrfmcw

Facility 1Vumber: 161 — Date of Inspection
Required Records &_Documents �,�
19. Did the facility fail to have Certificate of Coverage & Permit readily available? El Yes L[ No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes dNo ❑ NA ❑ NE
the appropirate box. ❑ WUP ❑ Checklists ❑ Design El Maps ❑ ether
21. Does record keeping need improvement? If yes, check the appropriate box below. E Yes ❑ No ❑ NA ❑ NE
❑ Waste Applicat' n ❑ Weekly Freeboard ❑ Waste Analysis El Soil Analysis ❑ Waste Transfers El Annual Certification
El 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 G-go ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
ETNo
❑ NA
❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
2es
❑ No
❑ NA
❑ NE
25. Did the facility fail to conduct a sludge survey as required by the permit?
f Yes
No
El NA
El NE
26. Did the facility fail to have an actively certified operator in charge?
❑ Yes
,❑l
I� 1vo
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
❑ No
2CIA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP`?
El Yes
,,�
LI No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
O-<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
014o
❑ 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
ElL�
,—,
'[vo
❑ 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
[jNo
ElNA
ElNE
33.
Does facility require a follow-up visit by same agency?
ElYes
O / No
❑ NA
❑ NE
Comments and/or Drawings:
12128104

Division of Watcr' uali
Facility Number L� .Division of.Soil and Water Conservation.
. , .
():Other Agency.:::
Type of Visit Co pliance Inspection Q Operation Review Q Structure Evaluation Q Technical Assistance
Reason for Visit (3 Routine Q Complaint ❑ Follow up 0 Referral Q Emergency Q Other ❑ Denied Access
Date of Visit: dt, I Arrival Time: Departure Time: County: +- Region:
Farm Name: Owner Email:
Owner Name:
Mailing Address:
Phone:
Physical Address:
Facility Contact: C� Title: Phone No:
Onsite Representative:JlhNErS�j �� sjA�C �►..j�b lntegrator:
Certified Operator:
Back-up Operator:
Location of Farm:
Design Current .
Swine . Canacitv Ponulatinn
77
ins
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gists
Boars
'Other.
Operator Certification Number:
Back-up Certification Number:
Latitude: = o [__1 ` 0 " Longitude: = o ❑ ' F-1 u
Design.::' : Current Design,'<-::''� Ctirr."ent
Wet Poultry Capacity'Population' : Cattle' :. ;:;` Capacify .Yopulatiuri
Layer
Non -Layer
Dry Poultry
Layers
Nan-L.
Pullets
Puuets
El Dairy Cow
❑ Dairy Calf
❑ Dairy Heifer
❑ Da Cow
❑ Non-Dai
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'?
Page 1 of 3
:`I
❑ Yes 2 No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes Zo
[I NA El NE
❑Yes ❑NA ❑NE
12128104 Continued

Facility Number: ?j _ Date of Inspection 6 ni.
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes Lp 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: L A%oa70
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes
ElNA ElNE
(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?
thrat, notify DWQ
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmentaTNo
7. Do any of the structures need maintenance or improvement? El 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
`No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes
j
LTV ❑ NA ❑ NE
maintenance/improvement?
11. is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes
No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 1 D% or l0 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) 9eL4 W 5G 0
13. Soil type(s)
[r
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
u 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 acre determination ?
❑ Yes
dNo ❑ NA
Cl NE
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
FN ❑ NA
❑ NE
Comments (refer to question #): Explain any YES answers and/or any recommendations or, an
F
Use drawings of facility to better explain.situations..(use.additional pages. as,necessury}:. ;;°;
rA It.r-, MO i7---[.o"S [60K-, "mD . GET k,'J A zUTE6L(L.AT0,_ Fo r4 c.TaRx=r x-, •
Reviewer/inspector Name I Ctv!-IP,,3 I Phone: 410,rN6" 7o7.tfl
Reviewer/Inspector Signature: Date: ! aC;

Facllity Number: —its
Date of Inspection to
fly
uired_Recards &_Documents
19.
Did the facility fail to have Certificate of Coverage & Permit readily available?
❑ Yes
2No
❑ 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 ❑ Other
21.
Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
L-!� 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
YNo
❑ NA
❑ NE
23.
if selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
L✓J No
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the pen -nit?
❑ Yes
❑ No
ElNE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
ElYes
[INo
NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
ff No
❑ NA
❑ NE
27,
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
❑ No
E! NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
L7 No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
LJ 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?
El Yes
,_,/
ONo
❑ 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
QNo
❑ 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
EJ`No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
�No
❑ NA
❑ NE
Additional Comments and/or Drawings:
Page 3 of 3 12128104

Type of Visit -0 Compliance Inspection Q Operation Review Q Structure Evaluation Q Technical Assistance
Reason for Visit �c� Routine O Complaint ❑ Follow up O Referral O Emergency ❑ Other ❑ Denied Access
Date cif Visit: rriF°al Time: _ G Q Departure Time: County:
r
Farm Name: =�_ _ Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: Title: Phone No:
Onsite Representative: . � Pn V I_M-5 Integrator: ui
Certified Operator: Operator Certification Number:
Back-up Operator:
Location of Farm:
Back-up Certification Number:
Region: T�' ` c�
Latitude: = n= I 0 �Longitude: 0 u= g
Design Current Design Current
Swine Capacity Population Wet Poultry Capacity Population
❑ Wean to Finish 110 La er
❑ Wean to Feeder 10 Non-Layet
Feeder to Finish I .3 C%
❑ Farrow to Wean Dry Poultry
❑ Farrow to Feeder
❑ Farrow to Finish ❑ La ers
❑ Gilts ❑ Non -Layers
❑ Boars ❑ Pullets
Other
❑ Other
Other
Pou lts
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State'? (If yes, notify DWQ)
Design Current
Cattle Capacity Population
❑
Dairy Cow
❑
Dairy Calf
❑
Dairy Heifei
❑
Dry Cow
❑
Non -Dairy
❑
Beef 5tocket
❑
Beef Feeder
❑
Beef Brood Cow
c. What is the estimated volume that reached waters of the State (gallons)"
Number of Structures:
d. Does discharge bypass the waste management system? (If yes, notify D WQ)
2. 1s 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 Z No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes e No ❑ NA ❑ NE
❑ Yes VrNo ❑ NA ❑ NE
12128104 Continued

Facility Number: I I — 3 Date of Inspection .3
Waste Coll ion & Treatment
4, Is stdrage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Structure 1 Structure 2 Structure 3 Structure 4
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): p�
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 A {"No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
❑ Yes ZNo ❑ NA ❑ NE
❑ Yes J`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 .21No ❑ NA ❑ NE
8, Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes 2 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 ElNE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives (hat need ❑ Yes 2 No ❑ NA ❑ NE
maintenance/improvement?
11, is there evidence of incorrect application? If yes, check the appropriate box below, ❑ Yes 2 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 Drifl ❑ Application Outside of Area
12. Crop type(s)
13. Soil type(s) i/ d
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
ZNo
❑ NA
❑ NE
15. floes the receiving crop and/or land application site need improvement?
❑ Yes
01�o
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination',[]
Yes
,2&o
❑ NA
❑ NE
17, Does the facility lack adequate acreage for land application?
❑ Yes
D o
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
lT ge
❑ NA
❑ NE
Reviewer/Inspector Name!' -
- -/ram+ ,.s �-,Y�.'w:�� �ys^� a)p���"� - Phone:
Reviewer/Inspector Signature: Date: 3 a
12/28/ 4 Continued

Facility Number: — Date of Inspection Q
Re wired &cprds & Documents
19. Ditl the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes j2'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 P,115esign ❑ Maps ❑ Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes ;2 No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and l" 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 2No ❑ NA ❑ NE
❑ Yes [2-No
❑ NA
❑ NE
❑ Yes ❑ No
E3 &A
❑ NE
❑ Yes ❑ No
12-NA
❑ NE
❑ Yes 2"No
❑ NA
❑ NE
❑ Yes ❑ No
❑ NA
ZNE
❑ Yes ,2 No ❑ NA ❑ NE
❑ Yes ONo ❑ NA ❑ NE
❑ Yes �No ❑ NA ❑ NE
Cl Yes Z No ❑ NA ❑ NE
❑ Yes E No ❑ NA ❑ NE
❑ Yes P/No Cl NA ❑ NE
Adtlitlonal CatuM. and/o0.Drawln s: 4.a `, ' , ;; ,'^r ;;':. ' �: " "`'.
yr..:[ . ra... • x...:e•.,.Y 1i,•r'� �:.:.. «,ia+ka•�
°� �Cc t5
orc�.ec'��y .
u a. C c Q� a c�o� do&) ��
pteas e. I. fA 1 ��
'iIP'N rf`e-Cor&S11
I2/2VO4

L'
I'lateorvisit; �J i � D Tune: Q d
FFacility Number
Q Not Operational Q Below Threshold
Permitted PrCertified 13 Conditionally Certified 0 Registered Date Last Operated or Above Threshold: .........................
FarmName: ..... 1Lr.AzY...... .. a ...1ta kY.v........._...................................................... county:... . ..... .................. ...... ........ ......... .....
Owner Name:.......................................................».............................,................................ Phone No:
MailingAddress:........................................................................._...............................................................................................................................
FacilityContact: ............................... .............. ..................... .... Title:................................................................ Phone No: ,..................................................
Onsite Representative: k .,J r.. � lnf...... _............................................ Integrator: .... 1..i�W...�.!S........................ .... ....................
Certified Operator: ........... »......................................_... ... »................ ............... ................ Operator Certification Number:.........................................
Location of Farm:
❑ Swine ❑ Poultry ❑ Cattle ❑ Horse Latitude �•"��� Longitude �• ��� �«
Design. �` Current' "'; r' : ���'' Deli rent - �' :'.: '�> " i' Desi Current m
gM ;;.
Swinerv�'!
, ....,, ,
Ca! aei .Po ulatioa='j,'
pawl ;a.. l., Cattle N; ,
tr3'., Ca ci Po"ulation,. Ca act r"'Po ulatian
❑ Wean to Feeder
;
❑ Layer
;I
❑ Dairyy
ElT eeder to Finish
p
❑Non -Layer.
Non -Dairy
Farrow to Wean
Farrow to Feeder
Other_
p
El Farrow to Finish
.:e ..: ::..:.:.......� ! JS;I
Y
'r � [i "� S'i1' Ci3 M
Gllt5El
pC1t ,
..:
Boars
r� *,� �+�ii��
�' � s i:: ri:r'':1�Qii�1'�7�71/W
aa. • _
{. li^jfl�✓.•=�Number.". of Lagoons:; i��. ,,:, � L.-'�::..
�'.+��i�'Holdin� Ponds l Salirl Trans.: !,; ?;.,; , ., .- .•� �,,: � .. .. ',,
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made?
b. If discharge is observed, did it reach Water of the State? (If yes, notify DWQ)
c. If discharge is observed, what is the estimated flow in gal/min?
d. Does discharge bypass a lagoon system? (If yes, notify DWQ)
2. Is there evidence of past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge?
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ SpiIlway
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5
Identifer: .........» .I ... ...................... ............ ...... .._... .... ............... .... .......... ........................... ........ ...................................
Freeboard (inches):
12112103
❑ Yes XNo
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes
❑ No
❑ Yes
VNo
❑ Yes
2fNo
❑ Yes ;?No
Structure 5
Continued

Fhcility Number: 3 ( — Date of Inspection
S. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, ❑ Yes XNO
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or ❑ Yes PINTO
closure plan? f
(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 maintenancelimprovement? ❑ YesXNo
8. Does any part of the waste management system other than waste structures require maintenance/improvement? ❑ Yes XNO
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level ❑ Yes No
elevation markings?
Waste Application
10. Are there any buffers that need maintenancelimprovement? ❑ Yes QrNo
11. Is there evidence of over application? If yes, check the appropriate box below. ❑ Yes VNO
❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload ❑ Frozen Ground ❑ Copper and/or Zinc
r
12. Crop type ecayytum l 4A r_.,r_Am� DV4ascEfl
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAVW)? ❑ Yes 1ZNo
14. a) Does the facility lack adequate acreage for land application? ❑ Yes 0 No
b) Does the facility need a wettable acre determination? ElYes XNo
c) This facility is pended for a wettable acre determination? ❑ Yes XNo
15. Does the receiving crop need improvement? ❑ Yes ANo
16, Is there a lack of adequate waste application equipment? ❑ Yes Na
Odor 14,,sues
17. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge attor below ❑ Yes �No
liquid level of lagoon or storage pond with no agitation?
18. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes 9No
19. Is there any evidence of wind drift during land application? (i,e. residue on neighboring vegetation, asphalt, ❑ Yes )ZNO
roads, building structure, and/or public property)
20. At the time of the inspection did the facility pose an odor or air quality concern? If yes, contact a regional ❑ Yes 1rNo
Air Quality representative immediately.
::t1"I13'^'i•i ,!(^ 1Y/,•' ;1 A.V. •'•. rtif•:i r:�ii .:L•• cc11""3��'Fi{�F's3i-rFi•. "�4,tu`?:ry�yi3ni::x ssiiexas.._ -:$ Lmi': »'ix ":a$.`:: °':TL¢,s 'ta:" c::: "4:•.' .:s:.::•.:.T.
Comments,(refer, to uestinn # : "F�t lean an �Y&5'answers'andlar an racoi°rttraeitdation's
.Use d�awings af�facihty:;ta'better explain sltusan�.(iese`addi onslpag.,. as neeessdry Field Co Final Notes '�:.; J;';:f
'y:•�yel;.aa:;. g: .•,�;� �:�,� s:;�'<,;g�..:e �.F., ,� �p �:t` ..:a? f., ,:n:...;;: ❑ PY ❑ S:� �:.
.:�Si�r "rt: •:,r., a. :s:. �-r3�y �`„Ls'�jil` "{�H y"Z, ti'Nj:. � {�� . ..:.::�:: .:� „�.�. • �.`•�.:.
vim• ,a
Z6-�bS N A q G &Elj WR-kk-t 06-� ,
Rw.5 �1 A" ()LC) So vu. t�DAT�S
� c��D S ►ICf�-�' +'tC,E
Review:I `��JAc�r{:i;ssE� �—:r.Q �•ul o!+; ..t�'!, .,;.p9:y.7�.•r.i�:?_r .:l]i,i�...?rerllnectorName
wer/Inspector c5...I,>• F::. ,.,K.�... „iyy�..y..::: s..a<':a«..a.`.:.,. {., .Eh1.N. ..�.�s.i�.w:Pi<:::N:.r......,.:.,�Y...Signature: Date:
12112103 Continued

Facility Number: Date of Inspection
Reauired Records & Documents
21. Fail to have Certificate of Coverage & General Permit or other Permit readily available? ❑ Yes)'No
22. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(iel WUP, checklists, design, maps, etc.) ❑ Yes X!
No
23. Does record keeping need improvement? If yes, check the appropriate box below, ❑ Yes XNo
❑ Waste Application ❑ Freeboard ❑ Waste Analysis ❑ Soil Sampling
24.
Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes No
25.
Did the facility fail to have a actively certified operator in charge?
❑ Yes �No
25.
Fail to notify regional DWQ of emergency situations as required by General Permit?
(iel discharge, freeboard problems, over application)
❑ Yes No
27.
Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes No
28.
Does facility require a follow-up visit by same agency?
❑ Yes X No
29.
Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes No
NPDES Permitted Facilities
30.
Is the facility covered under a NPDES Permit? (If no, skip questions 31-35)
❑ Yes gNo
31.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes ❑ No
32.
Did the facility fail to install and maintain a rain gauge?
❑ Yes ❑ No
33.
Did the facility fail to conduct an annual sludge survey?
❑ Yes ❑ No
34. Did the facility fail to calibrate waste application equipment? ❑ Yes ❑ No
35. Does record keeping for NPDES required forms need improvement? If yes, check the appropriate box below. ❑ Yes ❑ No
❑ Stocking Form ❑ Crap Yield Form ❑ Rainfall ❑ Inspection After 1" Rain
❑ 120 Minute Inspections '❑ Annual Certification Form
❑ No violations or deficiencies were noted during this visit. You will receive no further correspondence about this visit.
12112103

I Type of Visit jo Compliance inspection Q Operation Review 0 Lagoon Evaluation
jl Reason for Visit jb Routine Q Complaint Q Fallow up Q Emergency Notification 0 Other ❑ Denied Access
Facility Number Date of Visit•.
Permitted d1certifled © Conditiona11 Certified © Registered
Farm Name:
Owner Name:. _ F _- W AJ
Mailing Address:
rri��
Date Last Opera" or Above Threshold: _
County: �Lz�
Phone No:
Facility Contact: Ti e.- J Phone No:
Onsite Representative *'
Certified Operator: Operator Certification Number:
Location of Farm:
Swine ❑ Poultry ❑ Cattle ❑ Horse Latitude ' ° 0�6 Longitude '
Design Current Design Current Design Current
Swine Capacitv Population P ultry Capacitv Population Cattle Ca aci Population
❑ Wean to Feeder-❑ La er ❑Dai
Feeder to Finish ji IQ Non -Layer I I UNon-DaiTy
Farrow to Wean
El Farrow to Fecdcr ❑ Other
❑ Farrow to Finish Total Design Capacity
❑ Gilts
Boars Total SSLW
Number of Lagoons 1L Subsurface Drains Present j U Lagoon Area Spray Field Area
Holding Ponds 1 Solid Traps No Liquid Waste Management S stem
Discharges &Stream Impacts
I. Is any discharge observed from any part of the operation? ❑ Yes �J No
Discharge originated at; ❑ Lagoon ❑ Spray Field ❑ Other I
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 1 Structure 2 Structure 3 Structure 4 Structure 5
Identifier;
Freeboard (inches): _�2y
05103101
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes No
❑ Yes No
❑ Yes XND
Structure 6
Continued

a
Facility Number: slate of ]n.spection Printed on: 7/2112000
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, ❑ Yes PT No
seepage, etc.) PT
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or
closure plan'? ❑Yes /No
(If any of questions 4•6i 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 INo
8. Does any part of the waste management system other than waste structures require maintenance/improvement? ❑ Yes P(No
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings? ❑ Yes )dNo
Waste Application
10. Are there any buffers that need maintenance/improvement? ❑ Yes XNo
11, is there evidence ofover application? - ❑ Ex essive Ponding [_—]PAN ❑Hydraulic t]verlo ❑ Yes No
12. Crop type 2r
13. Do the receiving crops differ with those designate to the Certified Animal Waste Management lan (CAWM ? ❑ Yes No
14, a) Does the facility lack adequate acreage for land application? ❑ Yes VNo
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
Reguired
17.
Records & Dneuments
Fail to have Certificate of Coverage & General Permit readily available?
❑ Yes
�No
18.
Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.)
❑ Yes
VNo
19.
Does record keeping need improvement? (icl 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
XNo
21.
Did the facility fail to have a actively certified operator in charge?
❑ Yes
PdNo
22. Fail to notify regional DWQ of emergency situations as required by General Permit?
(iel discharge, freeboard problems, aver application) ❑ Yes ONO
23. Did Reviewer/inspector fail to discuss reviewlinspection with on -site representative? ❑ Yes No
24, Does facility require a follow-up visit by same agency? ❑ Yes 40
25. Were any additional problems noted which cause noncompliance of the Certified AWMP? ❑ Yes jdNo
4 YIA 19VIS.O # Rdeo .0 re h Vrtng s.vsjte Ii 9Q tj� r.
• rorresp&ideike. ab' k this Niisit.
Camrnents (refer. to question #}, zE>�plain'ppy!YES
y�toanswers and/or, anyr ecomint
ll;� ilraw;uigs of faciltt`6etter explain situatl�ria: (use acldrtinr>EaI pages es neck
1-5 r F,��r� Asry c os
!S dPOAr&
F pr.,r /746 /�'1!! �j6/lr���Q/►�� Cjzk/�' /7'�Fi /��i�G
CIA 3175-�qoo
Reviewer/Inspector Name j �..'..,.ks�,;,�;c;L'i=a'•'
Reviewer/Inspector Signature: Date:..

a - 4•
Facility Number: late of tuspectinn
Odor Issues
26, Does the discharge pipe from the confinement building to the storage pond or lagoon Fail to discharge atlor below ❑ Yes
liquid level of lagoon or storage pond with no agitation? II
27. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes ONo
28. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt, ❑ Yes ?'No
roads, building structure, and/or public property)
29, Is the land application spray system intake not located near the liquid surface of the lagoon? ❑ Yes �No
30. Were any major maintenance problems with the ventilation fan(s) noted? (i.e. broken fan belts, missing or
or broken fan bladc(s), inoperable shutters, etc.) ❑ Yes No
31, Do the animals feed storage bins fail to have appropriate cover? ❑ Yes JNo
32. Do the flush tanks lack a submerged fill pipe or a permanentltemporary cover? El Yes Qj No
MonaComments and/or Drawings:
J

rr:;
r "I',.
®Di►isioit-6f Water Quality
y�
Division of.Soil and Watet' Conservation
'
c A Other gen
t'. Yr ' - t
"•Y:'e w. !
.��K.ti 7:
_ 7. i i.. -
,�„ �:�: �
� -,,,; • r'�ti��: �
,:
� ;��. �✓:ate,
of Visit ® Compliance Inspection p Operation Review Q Lagoon Evaluation
Reason for Visit 41 Routine ❑ Complaint ❑ Follow up Q Emergency Notification ❑ Other ❑ Denied Access
Facility Number f Date lit Visit: �'Hme: Printed on: 7/21/2000
NNot Operational Q Below Threshold
® Permitted ® Certified © Conditionally Certified 13 Registered Date Last Operated or Above Threshold: ..•.•..•..••••••..•••..••
a 0
LhIZY S �R 2- K.5 Count ¢�-t'`I
FartnName; .............................................................................r................ 1 hone No• .�i.`...........�......F............... ...................-.....-..
Owner Name: ...... �4K6.7 �,�rat:.0 fpwN .1 k. I�vltr5 � .........0...3 `'} g0
3r .%00
................................................ ...
Facility Contact: P!!�L6S... r,..g.t* i1!!�. .....}.S� ~ t Fitle:......O.w �3 ........... ....... Phone No:.a`�Z ". a ....................
Mailing Address: Ig ,C l�ta LJ n. ur4P.l:N....... .0...................vigS ,I-:.?...........
.......................................................
Onsite Representative:.. JRMi �i .... � �n•�l.'�....................................................... Integrator:..--. �!r'aufj ........................................................
Certified Operator:. C!.$p?!!!s4���K►•p- ,Sk►a6Tr3 peratioorr�[C'ertification Number:.....�.90 8..................
Location 'nf Farm:
50,1*4+ OF �wNT» o►-la-�.� onsia►a b Pua t,►l AT �ti1 D a� 1 D
5R 1715.
Q Swine ❑ Poultry ❑ Cattle ❑ Horse Latitude ©� ®` ys Longitude 1 77 '
Swine
Design Current Design Current
Capacity Population Poultry Capacity Population
❑ Layer
1 S O ❑ Nero -Layer
❑ Wean to Feeder
Feeder to Finish
El Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
❑ Other
Design Current
Cattle Capacity Population
❑ I)airy
❑ Non -Dairy
Total Design Capacity 1'f `k6
Total SSLW 1,7% /00
Number of Lagoons ❑ Subsurface Drains Present ❑ Laglunn Area ❑ Spray i:ield AreN
Holding Ponds 1 Solid Traps ❑ No Liquid Waste Management System
Discharees & Stream Impackti
1. Is any discharge observed from any part of the operation? El Yes KIo
Discharge originated at: [_1 Lagoon El Spray Field El Other
a. If discharge is observed, was the conveyance man-made'' ElYes ❑ No
h, if discharge is ohserved, aid it reach Water of the Sta(e'' (ii yes, notify DWG]) ❑ Yes ❑ No
c. If discharge is ohs.:rved- what is the estimated 11ow in galhnin?
(1, 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? El Yes 5'No
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes XfNo
Waste Collection & Tre:atntent
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway ❑ Yes KNo
SlrtletUTC 1 SIYUC;LUTc 2 Structure, ? Structure 4 Structure 5 Structure 6
#... .........
Freeboard (inches):
5/00 Continued on back

Facility Number: 3 l -- 53 Vate of Inspection i Z !L Ga 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 ULNo
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or
closure plan? ❑ Yes 01 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 maintenancelimprovement? ❑ Yes ,�No
8. Does any part of the waste management system other than waste structures require maintenancelimprovement? ❑ Yes j�(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 kNo
i t . Is there evidence of over application? ❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload ❑ Yes kNo
12. Crop type CQ+"Q S 4- oote!rxa r +cat ►�
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)? ❑ Yes JKNo
14. a) Does the facility lack adequate acreage for land application? ❑ Yes XNo
b) Does the facility need a wettable acre determination? ❑ Yes 19No
c) This facility is pended for a wettable acre determination? ❑ Yes 9No
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, freeboard, waste analysis & soil sample reports)
20. Is facility not in compliance with any applicable setback criteria 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?
06 discharge, freehoard problems, over application)
23. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative'?
24. Does facility require a follow-up visit by same agency?
25. Were any additional problems noted which cause noncompliance of the Certified AWMP?
Io yi01'a 16As:or d+ Feiendpi -W rp npt;ea dewing t. s;visit; Yojx ;wi�� rteveiye tiro fueftr.
... ..
corres ondertce. a�auf this visit.. ' . .. .... .
❑ Yes IVNo
❑ Yes SIo
❑ Yes KNo
❑ Yes A No
❑ Yes RfNo
❑ Yes No
❑ Yes No
❑ Yes 110 No
❑ Yes ONo
❑ Yes Z' No
❑ Yes b(No
Comments (refer to question #): Explain any YES answers and/or any recommendations or any other comments.
Use drawings of facility to better explain situations. (use additional pages as necessary):
hCIA ®rl 5 t t t*_Sonr► j•e.u4ZI 5 A- rajAfkAL 4a fig...
5+o o,k451 5 Stn+ o F4- ric+ bdc I AA-.
I a a�� �r.. k"s la It r 4A 2,w,,, ` nod- [q " 6..1" 14"J
t." S + G C14t nor q aA•V-
IV
Reviewer/Inspector Name
Reviewer/Inspector Signature: _ Date: / dD 5/00

Facility Number: j Date of inspection Printcd on: 7/21/2000
Odor Issues
26. hoes the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge a11or hPlow ❑ Yes JK 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 C. No
28. Is,[here any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt, ❑ Yes No
roads, building structure, and/or public property)
29. is the land application spray system intake not located near the liquid surface of the lagoon? ❑ Yes I(No
30. Were any major maintenance problems with the ventilation fan(s) noted? (i.e. broken fan belts, missing or
or broken fan blades), inoperable shutters, etc.) ❑ Yes 6"No
31. Do the animals feed storage bins fail to have appropriate cover? ❑ Yes VNo
32. ❑o the flush tanks lack a submerged till pipe or a peimanent/temporary cover? ❑ Yes
it onaComments and/or Drawings: ... ,
J
5/00

Division of Soil and Water Conservation - Operation Review
f E E3 Division of Soil and Water Conservation.- Compliance Inspection
Division of Water Quality-,. Compliance.Inspe0on '
a
©Other Agency - dperation k'Aew
Routine. D Complaint Q Follow -a of DWQ inspection Q Follow -tie of DSWC review ❑ Other
Facility Nutnher Date of Inspection
1'im4 of inspection ] 24 hr. (hh:mm)
Permitted C] Certified j,] Conditionally Certified E3 Registered JE3 Not O erational Date Last Operated:
FarmName: .............�......... .......-. ............... county: ......iXU.. ....... -... .......................
Owner Name:.... r1°tires.- , ................ ... [ .C�.Q.t,t 1'lf�......... ..... ... Phone No: '. .�...I........................
Facility Contact: ........ --.....Title: . ................ Phone No: gkc.).,02A.....�..Z�7
!Mailing Address: ..:`�.�r�......iL .L ifs.L7..fw..,r�,�...... 1-;LL7......L.r .�
t
Onsite Representative:. ,,f�;. ... a ............ Integratar:...� - .................. .�.r....... C ..l l .�.. s . �,7.-�n.. ,5 ..............
CertifiedOperator:........................................... ............................................................. Operator Certification Number:
Location of Farm:
W
Latitude 0 ®' •1 Longitude • ®' afl`,
Design Current. A': Design- Current Design Current
Swine Capacity PopulationCattle Capacity Population
' ❑ Wean to Feeder ❑ Layer ❑ Dairy
f_ZFecdcr to Finish ❑ Non -Layer ❑ Non -Dairy
❑ Farrow to Wean
❑ Farrow to Feeder 10 Other
❑ Farrow to Finish
a @ Ci Tvt 1�D Sign Capa 'ty
❑ Gilts',
❑ Boars Total SSLW
Number of Lagoons ❑ Suhsurface Drains Present ❑ Lagoon Ares ❑ Spray Field Area
n �.,:
Holding Ponds l Solid.Traps JE1 No Liquid Waste Management System
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation? ❑ Yes $(No
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made'! ❑ Yes N�f No
h. If discharge is observed, did it reach Water of the State? (I1'yes, notify DWQ) ❑ Yes $;�No
c. If discharge is observed, what is the estimated flow in gal/min?
d. Does discharge bypass a lagoon system? (if ycs, notify DWQ) ❑ Yes PNo
2. Is there evidence of past discharge from any part of the operation'? ❑ Yes �(No
3. Were there any adverse impacts of potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes WNo
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway ❑ Yes XNo
Structure I Structure 2 Structure 3 Stnicture 4 Structure 5 Structure 6
Identifier:
Freeboard(inches): ..........-�'.��......... ........................ .................................... ...................................
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, [] Yes �No
seepage, etc.)
3/23/99 Continued on back
S

Facility Numher: Date of Inspection
6. Arc 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 part 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 Application
]a. Are there any buffers that need maintenancelimprovement?
11. Is there evidence of over application? ❑ Excessive Ponding' ❑ PAN
12. Crop type
13. Do the receiving crops differ with those designated in the Certified Admal 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?
Re wired 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?
(iel WUP, checklists, design, maps, etc.)
19. Does record keeping need improvement? (icl irrigation, freeboard, waste analysis & soil sample reports)
20, I% facility not in compliance with any applicable setback criteria 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'?
(iel discharge, freeboard problems, over application)
23, Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
24. Does facility require a follow-up visit by same agency?
25. Were any additional problems noted which cause noncompliance of the Certified AWMP?
Ia -yioloos .oi� ii0#•iciertcies •were izp#ed. 0uririg Ns'visit; • Your *ill eetriye ijd flif tiler.: .
:�:•correst�oridence.a�gutithi�:visit.•....•.•.-.-.-.�:......•...�.•.•.•.'.-.•.-............. -.�........
.... .
Comnienfs (refer:'.to question'#) ' Cxplam any YES"answers and/or any recommendations or any other comments:
C1se'diawinis of facility to better explain situations. (use additionalrpagcs'as necessary): 1 € ' .
l�►r�A,55- --kn0W �GL7� pc�Dt-tCr _[-�e✓�-
t---t Ln �-_- C7•-vN --,c�-� --rt-� S L �-_) �--- 0 G7' b ►, c
(,-:kq
❑ Yes NNo
❑ Yes No
ElYes &NO
w' w, "
❑'Yes %IffNo
❑ Yes ),�'No
❑ Yes `<No
❑ Yes Flo
❑ Yes Na
❑ Yes o
❑ Yes No
❑ Yes ZNO
o
ElYes
❑ Yes XNo
❑ Yes J<No
❑ Yes )qNo
❑ Yes No
❑ Yes ❑
❑ Yes 11�No
❑ Yes No
❑ Yes No
❑ Yes )j(No
ReviewerfIns ector Name p, _. ,.- _._.._ P # j� _.:. H ,,. a .. - ^. •._{
Reviewer/Inspector Signature: t-j_� ��� _ A �� �, Date: t i
3/23/99

1, . clq
j `Facil'ity Number; ^-�_%;--�I Il:,tc nf' in,pection G`p,
Odor Issues 1
26. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below ❑ Yes XNo
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes 9No
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 `No
30, Were any major inaintcnance problems with the ventiiation fan(s) nosed? (i.e. broken fan belts, missing or `` \\
or broken fan bladc(s), inoperable shutters, etc.) ❑ Yes �-KNo
31. Do the animals feed Storage bins fail to have appropriate cover'? ❑ Yes V
o
32. Do the slush tanks lack a submerged fill pipe or a permanent/temporary cover'? Yeso[7•��
Act lxttonal 4umments and/or Drawings: ..
3/23/99

t A.
❑ 1=}SW C Animal Feedlot Operation Review
DNNIQ Animal Feedlot Operation Site Inspection
Itoutine ❑ Conip saint D F3Ilaw-u of D %VQ ins Letiun Q F n1l nw-uE or DSWC revium, Q Other
Bate of Inspection f
Facility Number S Time of Inspection 24-hr. (hh:mm)
p Registered ;j Certified 17 Applied for Permit U Permitted JE3 Not C? erational Date Last Operated:
Farm Name: ........ .J.,[t z .... .....rrxri k ....... .....» ...... ....._ .... _ ...._:. County':.. ................_».. »................
Owner Name: ...... _.. .. .�k5t:�...... ......... ......... _»...__... Phone No:......� �Q� :i ce` .�. ��i... _. ....... ..... ..........._.......
Facility Contact: . ...... . .... . .... . ..... . ..... . ............ ....._.» Tii1e:.. ».... ... ..._.. _ .._........ .. Phuneltio:...................»_._... .
Mailing Address; ... ZL�....».......... _ .... »....-........
�?
OiMte ReprosentativG:.._ .... �.cse ... eni�...................... ............. ........._..... Integnstor:.......wltis�............-........................
Certified aperatflrt.. ....... _ .._......_ .. .._.... K....� ..._.._�.. Operator Certification Number:
Location of Farm:
... ..... ............... ..... _._ ... »....._ .........._._....»........... .»....... .»...... .......... ........ ......... .»... .....�.». _ .... �A.
- --- . -
Latitude Longitude
Longitude
`Swinewrl
.Design . .-.:Current : Design : Current ; xDestgtii
Capacity.; Popuiatioa l' .:Poultry. Capacity .Population • Cattle °'Capacit
❑ Wean to Feeder
Feeder to Finish
t[
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
❑ Layer Dairy
❑ Nan -Layer I t ]ONon-Dairyj
10 ether I L
Totiil.Desian Capacity.
... r • Total 55LW'
m I�iatxiber.of Lagoons./Holding Paads`'� ❑ Subsurface Drains Present ❑ Lagoon Area ❑ Spray Field Area
.. .. ... ... o squi Oslo Management System
ne 1
I. Are there any buffers that need maintenanceiimprovement? ❑ Yes ;Q No
?. Is any discharge observed from any part of the operation? ❑ Yes EP No
Discharge originated at: ❑ Lagoon D Spray Field ❑ Other
a. If discharge is observed, w•ac the conve_rance man-made? ❑ Yes No
b. if discharge is obsen-ad. did it reach Surface Watcr? (If yes. notify DWQ) ❑Yes No
c. If discharue is observed, what is the estirram'd flow in gallmin? IV
d. Drees discharge bypass a lagoon sy=stem? (If yes, notify DWQ) ❑Yes ®No
"a. Is there evidence of past discharge from any part of the operation? ❑ Yes ® No
4. Were there any adverse impacts to the waters of the State other than from a discharge? ❑ Yes © No
5. Does any part of the waste management system (other than lagoons/holding ponds) require ❑ Yes [ ] No
maintenance/improvement?
6. Is facility not in compliance with any applicable serback criteria in effect at the time of design? ❑ Yes No
7. Did the facility fail to have a certified operator in responsible charge? ❑ Yes ++� No
7125197
Continued an hark

F acilit} '� umber: 3 l —4Q1
S. Are there lanoons or storage ponds on site which need to be properly closed?
S•truVures 1Lap onns.Hold, ingPnn�_F'Ius11.P etc.1
9. 1s storage capacity (freeboard plus storm storage) less than adequate?
❑ Yes 1P No
❑ Yes [P No
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifierw . _. ..._.� .._ ...._ ..... ........ ..... ._........ ........ _ ...._ ... _ .. » . _.. .....
Freeboard(it):......_ .. _ ...... ___ ..... »......_ _...... ... »..... _ _...� _....._ ........._... ..... ..... ......_. _ .. _.......
10. Is seepage observed from any of the structures? ❑ Yes ED No
11. Is erosion, or any other threats to the integrity of any of the structures observed? ❑ Yes MNo
12. Do any of the structures need maintenancelimprovernrm?
(If any or 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?
Waste Application
14. Is there physical evidence of over application?
(If in excess of WMP, or runoff entering waters of the State, notify DWQ)
15. Crop type .. .....
._ ._.�� ._ �tN.►i]7i._ ... _..._ .. .
16. Do the receiving crops differ with those designated in the Animal Waste Management Plan (AWMP)?
17. Does the facility have a lack of adequate acreage for land application?
18. Does the receiving crop need improvement?
19. Is there a lack of available waste application equipment?
20. Does facility require a follow-up visit by same agency?
21. Did Reviewer/inspector fail to discuss mviewrnspection with on -Site representative?
22. hoes record keeping need improvement?
For Certified or Pe itted Facilities Only
23. Hoes the facility fail 'to have a copy of the Animal Waste Management Plan readily available?
24. Were any additional problems noted which cause noncompliance of the Certified AWMP?
>Ar 25. Were any additional problems noted which cause noncompliance of the Permit?
�] No.violations•or deficieiicie's. were nated•during t1iis:visiL- You_ .vd11 receive ho further
:��.•correspbridence�haettthis:vtsi#.,:� ::.�:�. . �.�.. ::. :�. :�..: .�:--��.�: .�,.• :�. ,•��.•
1MYes ❑ No
❑ Yes MNo
❑ Yes ER No
❑ Yes C. No
❑ Yes IN No
❑ Yes i9 No
❑ Yes ® No
❑ Yes ® No
❑ Yes ® No
❑ Yes q No
❑ Yes No
❑ Yes No
❑ Yes ® No
1 •�Lr6sbr. (Xmas on ky *% r-1dlOLL .Sal+ Shajljr 1 G '�y'I{.tr] vii ... c •1 vlTCetkjl Rom .a.t&,. ShOL)IJ
rt11_]�u LL, or, [nw,� �l l Kt t„i,t[ . Nr_ � 4t� a yoc)ej 6+f,, vTLu{ 1r �r�[.�T Pf 1 qe.
L-,
0M
7/25/97
Reviewerlln actor Name = • ; �,,,'.' _;;;, , ~ • ��, � �� �"' � w.
". •: �. , akrn, �r X::'%: �a A.i ss .-a.Uzi«��at;sw.•�r�+;;:.-::ik�'i7^.. ! '-�
Reviewer/inspector Signature:, Date:

` ��FF3" .�.; ��iy: ❑ Division of Soil and Watcr Conservation � �tller Agency ' :E: sif °__
:' . ieE3i•� ... qqyy ee
.� ' .3=, �. 's?£. i' si 3.,..v^.v.�.m=F`1x....�..^eer..Fe.....;..re•w-�..+w..ngy.^w•stS"'-"r;.""mR Y i,.....„,,,..H .n•.��....�n...=--»»-w,,,r....r... w,!^^. .. _ ,. ,...
&Routine D Complaint ❑ FolloK-up r,f I)' %"Q inspc�tiotl O Follrfw-ttp of i)swc review 0 Other
Date of Inspection to LiSlkJ
Facility Number
Time of Inspection l s : 24 hr. (hh:mm)
[3 Registered (.Certified © Applied for Permit 13 Permitted ;] Not ❑ perational Date Last Operated;,,,,,,,,,,,,,,,,,,,,,,,,,,
Fartn Narnc:.... -.tlL. .. ...............?FQ.r.►r,,f�......................... County: ..... V,,,tt .i.. .........................................
Owner Name ............ .,> .5. .,....ff,.,..,,.,..... .....,...................................... Phone No:....( i.C.0) .......... I............
FacilityContact: ...............................................Title:................................................................ Phone No:...................................................
MailingAddress :..... ��.`�.......�,1� �.sr�„�.�......� d.�.,dw.ti..,.................... lw..t�..�..as .q...s n. �.�. r,..l...fy.,,,........... .2 �.� �.�.....
Onsite Representative:...
s�.............�r.rA.xc 1.�.........................................-......... Integrator:.....
.
Certified Operatot':............................................................................................................... Operator Certification Number:.....................
Location of Farm:
.A i....& ..... c . „ 1, . 2.5:........................ ............................................................................................ ............. ............................................................
.....................................................
Latitude • ° " Longitude • 4 "
jD
esign urrent; Destgn urlwit cargo ._; :Current:
Swine ; !; "' _'`` .,,:; : 'Capacity Popti 14n Poultry.. '!.:: "': CairAcity i?upulation . Cattle Capaci{y Population
❑ Wean to Feeder
❑ Feeder to Finish
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
Number ; of xLagoons IHoldi, Ponds ❑Subsurface Drains Present ©i ❑ Spray Field Area
a:.. . Lagoon Area i
•, .
«.YS
ff ,
Fs
General
1. Are there any buffers that need maintenance/improvement? ❑ Yes ® No
2. Is any discharge observed from any part of the operation? ❑ Yes ® No
Discharbe originated at; ❑ Lagoon ❑ Spray Field ❑ Other
a. if discharge is observed, was the conveyance man-made? ❑ Yes RNo
b, If discharge is observed, did it reach Surface Watcr? (If yes, notify DWQ) ❑ Yes K5 No
c. If discharge is observed, what is the estimated flow in gallmin? - IJ[ A
A. 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 No
4. Were there any adverse impacts to the waters of the State other than from a discharge? ❑ Yes KNo
5. Does any part of the waste management system (other than lagoonslholding ponds) require ® Yes ❑ No
maintenancelimprove meet?
6. Is facility not in compliance with any applicable setback criteria in effect at the time of &,;ign? ❑ Yes EZNo
7. Did the facility fail to have a certified operator in responsible charge'? ❑ Yes 1KN❑
7/25/97
Continued on back

Facility Number: — y�
�- 8. Are there lagoons or'storage ponds on Site which need to be properly closed? ❑ Yes No
Structures (Lagoons,[ioldin Pnirris,_I lu,sb_1'its,_etc.1
9. Is storage capacity (Freeboard plus storm storage) less than adequate? ❑ Yes No
Structure 1 Structure ? Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Freeboard [ft}:
..............................................................................................................................................................
10,
Is seepage observed from any of the structures?
❑ Yes
$ZNo
11.
is erosion, or any other threats to the integrity of any of the structures observed?
❑ Yes
14 No
12.
Do any of the structures need maintenance/improvement?
[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
JR No
Waste APplirainir
14.
Is there physical evidence of over application?
❑ Yes
Q No
(If in excess of WMP, or runoff entering waters of the State, notify DWQ)
15.
Crop type .... ....................................................................................................................................
16,
Do the receiving crops differ with those designated in the Animal Waste Management Plan (AWMP)?
❑ Yes
Ed No
17,
Does the facility have a lack of adequate acreage for land application?
❑ Yes
1K No
18,
Does the receiving crop need improvement?
® Yes
❑ No
19.
Is there a lack of available waste application equipment?
❑ Yes
allo
20.
Does facility require a follow-up visit by same agency?
❑ Yes
10 No
21.
Did ReviewerlInspector fail to discuss re A ewh n spe c ti on with on -site representative?
❑ Yes
KNo
22.
Does record keeping need improvement?
❑ Yes
OLNo
For Certified or Facilities Only
23.
Does the facility fail to have a copy of the Animal Waste Management Plan readily available?
❑ Yes
allo
24,
Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
RNo
25.
Were any additional problems noted which cause noncompliance of the Permit?,
11
❑ Yes
JRtNo
No:v1O_N ionsnr deficiencies were. 6ted during this:visit..You�will irece'i've;rro ftirttier
cofrespotidence about this: visit:• '
,.. :...ie s • s,�: ..:.a e..e: �: . � :...� .... .... ��... .. .. i::.. .. .Fi".3�:E:::1::.
otnuxtents re er t4 question J:' Ex la man S::answers andlor an reco�t iifidAtinns=or an 'other comments ;; 3 R:
'.3. ... �:. »•s ,...: �.. �� ' n:. :ffs.,,:s�':':.::.. .. •�,i:� iiii..€3: is ..,wF::;ii' ilie '::.::: :: ........ $�..
se dro wings:of factltty to tiettcr ex lain sttuatistts:` use additiartal:pages;as. necessary): J'..(
�f;G Y• .'ii: F i . . s.Fi
. F „ .�..
S , 51.0.1. ; ► i � �► �-c�.t.. t,ti S p � �•e..4� � - e • y rw �g t �� � � a-•--� Y�,tl �a�- �.� �:.:,,�.�
t 2.-w-t.'j-� t o 1►t- s�-*`L S a E`S o ►'► D o m w o, L 1- AA4 o r o U w�-� t..s cwc il,d
o-v-e-V C.� f-t-t-�., _c_ e a e u t_ L a o K t..s cL 11 { p VV=
oLot
FeM �s+r.. eie�...=�... _ '.ii..v�'•:n <'.'ss mui ^'9sry
Reviewer/Inspector Narnc
r
F
FFI. � "1
ReviewerlInspector Signature: pt,-,ILD T f—j �„� � ,� hate:
7/25/97
IN

Site Requires Immediate Attention:
Facility No.
DIVISION OF ENVIRONMENTAL MANAGEMENT
ANIMAL FEEDLOT OPERATIONS SITE VISITATION RECORD
DATE. &--gQ- , 1995
.,Time: 3 C)
Farm Na
Mailing
County:
Integrator:
On Site Representative:
Physical Address/Location:
Phone:
Phone: %/� '(7
wi
Type of Operation: Swine Poultry Catt e�s-
Design Capacity: Number of Animals on Site: /' 10
DEM Certification Number: ACE DEM Certification Number: ACNEW
Latitude:' ► Longitude: :2 7•" Elevation: Feet
Circle Yes or No
Does the Animal Waste Lagoon have sufficient freeboard of I Foot + 25 year 24 hour storm event
(approximately 1 Foot + 7 inches) lb or No Actual Freeboard: 3 Ft. Inches
Was any seepage observed from the lagoon(s)? Yes or 1gWas any erosion observed? Yes or io
Is adequate land available for spray? Y or No Is the cover cc adequate? es r No
Crop(s) being utilized:
Does the facility meet SCS minimum setback criteria?. 200 Feet from Dwellings?�es or No
100 Feet from Wells? ( or No
Is the animal waste stockpiled within 100 Feet of USGS Slue Line Stream? Yes oro
Is animal waste land applied or spray irrigated within 25 Feet of a USGS Map Slue Line? Yes oa
Is animal waste discharged into waters of the state by man-made ditch, flushing system, or other
similar man-made devices? Yes oQj,� If Yes, Please Explain.
Does the facility maintain adequate waste management records (volumes of manure, land applied,
spray irrigated an specific acreage with cover crop) 7 Yes r No
Additional Comments: 7
i ..
Inspector Name
cc: Facility Assessment Unit
S ignature
Use Attachments if Needed.