310578_INSPECTIONS_20171231

NORTH CAROLINA
Department of Environmental Quaff

Type of Visit: m Compliance Inspection O Operation Review O Structure Evaluation O Technical Assistance
`
Reason for Visit: C7 Routine O Complaint 0 Follow-up O Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: Departure Time: Un= County: (/ Region:
Farm Name: Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact:
Onsite Representative: it 8a'D C, le —
Certified Operator:
Back-up Operator:
Title:
Location of Farm: Latitude:
Phone:
Phone:
Integrator: q q
Certification Number: r J
Certification Number:
Longitude:
Design Current
Swine Capacity Pop.
Wean to Finish
Wean to FeederFINon-Layer
Wet Poultry
Layer
I
Design
Capacity
I
Current
Pop.
Design Current
C►attle Capacity Pop.
Dai Cow
Dairy Calf
Feeder to Finish
Farrow to Wean
Farrow to Feeder
R7.9 P,oult .
I Layers
Design
Ca ei
Current
R,,Q
Dairy Heifer
D Cow
Non -Dairy
Beef Stocker
Farrow to Finish
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Other
Other
Turke s
Turkey Poults
Other
Discharees and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify 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 M No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes FNo
❑ NA ❑ NE
❑ Yes ❑ NA ❑ NE
❑ Yes ❑ NA ❑ NE
Page I of 3 21412015 Continued

Facrili Number: - Date of inspection:
Waste Collection & Treatment
4'is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes cl/wo ❑ 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 o ❑ NA ❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a ❑ Yes 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 rest, 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 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 YNo ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
n No ❑ NA
❑ NE
maintenance or improvement?
WNo
11. Is there evidence of incorrect land application? If yes, check the appropriate box below.
❑ Yes
❑ NA
❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (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
Q6 ❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ YesFNo
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
[] Yes
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
o ❑ NA
❑ NE
Required 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
❑ No
❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis
❑ Waste Transfers
❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections Monthly and 1" Rainfall Inspections
❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge?
❑ Yes
o
❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
No
❑ NA ❑ NE
Page 2 of 3
21412015 Continued

1Fadlli Number: - Date of Inspection:
s�_
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?
❑ YesgNo
❑ 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)
/No
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Yes
❑ NA ❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
34. Does the facility require a follow-up visit by the same agency?
Reviewer/Inspector Signature:
Page 3 of 3
❑ Yes
❑ Yes
❑ Yes
Date:
❑NA ❑NE
❑NA ❑NE
No ❑ NA ❑ NE
a� 1
21412015

Type of Visit: Q 7Routine
pliance Inspection Q Operation Review Q Structure Evaluation Q Technical Assistance
Reason for Visit: 0 Complaint O Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: Departure Time: County• (YLLLL
i Region:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Owner Email:
Phone:
Facility Contact: Title:
Onsite Representative: U S S Lq SR_oC-(< Integrator:
Phone:
Certified Operator: Certification Number:
Back-up Operator: Certification Number:
Location of Farm:
dean to Finish
Jean to Feeder
ceder to Finish
arrow to Wean
arrow to Feeder
arrow to Finish
Pullets
Other
Latitude:
Poults
Longitude:
Cy ow
Cy alf
Her eifer
Cow
Beef Stocker
Beef Feeder
Beef Brood Cow
a/qq(,o
Discharges and 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 DWR)
❑ Yes
❑ No
❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWR)
❑ Yes
❑NA❑
NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
❑ NA
❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters
❑ Yes
VNo
❑ NA
❑ NE
of the State other than from a discharge?
Page I of 3 21412014 Continued

Facility Number: jDate of Ins ection: 41141
Waste Collection & Treatment
4. lstctorage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes dNo ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structure Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: f � ult5j
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? El '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 (2 No ❑ NA ❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or env' onmental threat, notify DWR
7. Do any of the structures need maintenance or improvement? Yes ❑ No ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes [,] No ❑ NA ❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes WNco ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance altematives 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 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 C3No ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes C3"No ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes [a<o ❑ NA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
❑ Yes E2<o ❑ NA ❑ NE
❑ Yes [](No No ❑ NA ❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes N ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes II 1�� ❑ NA ❑ NE
the appropriate box.
❑ Wi1P ❑ Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑ Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes a<
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall [:]Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? [—]Yes �t
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes
[DNA ❑NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑NA ❑NE
Page 2 of 3 21412014 Continued

Facility 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`Ibe facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes No DNA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge? ❑ Yes o ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? []Yes VNo ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
❑ Yes 2(/No ❑ NA ❑ NE
❑ Yes dNo ❑ NA ❑ NE
❑ Yes M/No ❑ NA ❑ NE
❑ Yes [/�No ❑ NA ❑ NE
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes
34. Does the facility require a follow-up visit by the same agency? ❑ Yes
ZN ❑ NA ❑ NE
f
o ❑ NA ❑ NE
o ❑ NA ❑ NE
Comments (refer to question ft Explain any YES answers and/or any additional recommendations or any other comments..
Use drawings of facility to better explain situations (use additional pages as necessary).
�t CLcAlJ Sv" L.L -5_)QPCZk�
Av�'- Z'F(L fla n1C
Reviewer/Inspector Name:
Reviewer/inspector Signa
OFF 3-ACK_ o � E . CAcc,
tor
JoE.j FtAi Phone:( [1b)
e: Date: I g Alp
Page 3 of 3 21412015

Type of Visit: Co pliance Inspection O Operation Review p Structure Evaluation p Technical Assistance
Reason for Visit: Routine O Complaint O Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit: ff—ftLIS7 I Arrival Time: Departure Time: County: Dmad Region:
Farm Name:
Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact:
Title: Phone:
!r
Onsite Representative: V O' C*=
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Integrator:
Certification Number: e�_ L139 Y0
Certification Number:
Longitude:
Swine
Wean to Finish
Design C►urrent
Capacity Pop.
Design
Wet Poultry Capacity
La er
Current
Pop.
Design Current
Cattle Capacity Pop.
Dairy Cow
can to Feeder
I
jNon-Layer
El
Dairy Calf
Dairy Heifer
Feeder to Finish
Farrow to Wean
Design
Current
$o .
Dry Cow
Non-Dai
Beef Stocker
Farrow to Feeder
17 , P,oultr, Ca aci_
Farrow to Finish
Layers
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Turke s
Turkey Poults
Other
Beef Brood Cow
Other
Other
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWR)
c. What is the estimated volume that reached waters of the State (gallons)?
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 ❑ o
El Yes [fo
❑ Yes No
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Page l of 3 21412015 Continued

&ty
Number: Date of inspection:
e Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structure, I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier. 0 60UnNI
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes i2r 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 CNo ❑ NA ❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or7Yesonmental threat, notify DWR
7. Do any of the structures need maintenance or improvement? ❑ ❑ 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 UNo ❑ 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�j No
❑ 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 VNo
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes � o
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes [No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes VNo
❑ NA
❑ NE
the appropriate box.
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. [:]Yes No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1 " Rainfall Inspections ❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? ❑Yes VNo
❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? [:]Yes (DNA ❑ NE
Page 2 of 3 21412014 Continued

CNumber: - Date of Inspection: J`
2 xl tke facility fail to calibrate waste application equipment as required by the permit. ❑ Yes ZNo ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes CZINo ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge? ❑ Yes No ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes No ❑ NA ❑ NE
Other Issues
No
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
❑ 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
Wo
❑ 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
[nNo
❑ 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 [� o ❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes 5o ❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency? ❑ Yes [No ❑ NA ❑ NE
Comments (refer to question #): Explain any YES'answers and/or any additional recommendations or any other comments.
Use drawings of facility to better explain situations (use additional pages as necessary).
Eq f�cw+o� q rkahk asu_sx� E d D'I<rW ,
6PAQP�10� O� N66r i-W5E NEEID5 Atafl&.may
Reviewer/Inspector Name:
Reviewer/Inspector Signatui
Page 3 of 3
Phok:
Date: S l 1 K I(
5

9) rn ✓
(Type of Visit: 0 WRoutine
pliance Inspection U Operation Review Q Structure Evaluation Q Technical Assistance
sit:Reason for Vi0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: y J Arrival Time: Departure Time: ® County: ,01,Pt Region:
Farm Name: Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact:
Title:
Onsite Representative: GA6u As &�_o a_ Integrator:
Certified Operator:
Phone:
Certification Number: H 9 r
Back-up Operator: Certification Number:
Location of Farm:
Latitude: Longitude:
Design Current Design Current
Capacity Pop. Wet Poultry Capacity Pop.
Finish La er
rFeeder
Design Current
Cattle C*apacity Pop.
Dai Cow
Feeder
Non -La er
DairyCalf
o Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Design Current
1] , P,oul. C•_a aci P,o ,
La ers
Dairy Heifer
Dry Cow
Non -Dairy
I 113eef Stocker
Gilts
Non -Layers
I 113eef Feeder
Boars
Pullets
113eef Brood Cow
Other
Other
Turke s
Turkey Poults
Other
Discharees and 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
Vg�No
❑ 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

Fac flity 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: l
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):Z�
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
No
❑ NA
❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a
Yes
[Z No
❑ NA
❑ NE
waste management or closure plan?
If any of questions'4-6 were answered yes, and the situation poses an immediate public health
or environmentthreat,
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
❑ 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
26 No
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below.
[:]Yes
0 o
❑ NA
❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10%or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
Po
No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
E(No
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
P40
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
❑ No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
NNo
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
o
F/N
❑ NA
❑ NE
the appropriate box.
❑WUP ❑Checklists ❑Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rainfall Inspections ❑ Sludge Survey
22.'Did the facility fail to install and maintain a rain gauge? [:]Yes VNo
❑ NA ❑ NE
23. if selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑Yes ❑ NA ❑ NE
Page 2 of 3 21412011 Continued

•
Facili Number: - Date of Inspection: t
24. Did the facility fail to calibrate waste application equipment as required by the permit? Yes ❑ NAE❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes nNo ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey Cl Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge? ❑ Yes N ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes 5
o ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
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
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
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
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
C No ❑ NA ❑ NE
E No ❑ NA ❑ NE
No ❑ NA ❑ NE
/No ❑ NA ❑ NE
❑ ❑ NA ❑ NE
N ❑ NA ❑ NE
o ❑ NA ❑ NE
(Comments (refer to question #): Explain any YES answers and/or any additional recommendations or any other comments.
Use drawings of facility to better explain situations (use additional pages as necessary).
P�FE.b CAl2_62RT1or4 Doa.X a&,c-t-
— f n.-.E S C&_Uv tAov c, r� 6 c� �++�w�i L�q
DO 3� O CX'
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
! SEND T_J F6vi<
(;�C -t C-j s za r) Go'k-
Phonel C ^�
Date:
2141201)

Type of Visit: Q Co pliance Inspection U Operation Review O Structure Evaluation U Technical Assistance
Reason for Visit: Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: Departure Time: County: QJ01 Region:
Farm Name: Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact:
Title:
Onsite Representative: '�uSS e , — 3 P-a G{L Integrator:
Certified Operator:
Back-up Operator:
Location of Farm: Latitude:
Phone:
Certification Number: `2,19 I b
Certification Number:
Longitude:
Swine
Wean to Finish
Design Current
C•apatity Pop.
Design Current
Wet Poultry Capacity Pop.
La er
Design C*urrent
Cattle Capacity Pop.
Dairy Cow
Wean to Feeder
7�*
-Layer
Dairy Calf
Feeder to Finish
Design Current
MTY2P,oult . Ca aci P,o ,
ILayers
Dairy Heifer
D Cow
Non -Dairy
Beef Stocker
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Other
Other FTOther
Turke s
Turkcy 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 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 To ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
❑ Yes , No ❑ NA ❑ NE
❑ Yes o ❑ NA ❑ NE
Page I of 3 21412011 Continued

FadNumber: - Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
[4,>e
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No
❑ NA
❑ NE
Structure 1 Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
121<0
❑ NA
❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a
❑ Yes
No
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environme al threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes No ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes No ❑ NA ❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes 21 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?
15. Does the receiving crop and/or land application site need improvement?
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
the appropriate box.
❑�Yes
es ❑ No ❑ NA ❑ NE
❑ No ❑ NA ❑ NE
[—]Yes [r No ❑ NA ❑ NE
❑ Yes
❑ Yes No
❑ Yes 2 '�
[:]Yes Ta
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements
❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below.
eyes
❑ No
❑ NA FINE
❑ 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
❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
No
❑ NA ❑ NE
Page 2 of 3
21412011 Continued

Facility Number: - Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes VNo ❑ 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 f 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
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 We drains exist at the facility? If yes, check the appropriate box below.
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
❑ Yes 121<0
❑ Yes No
❑ Yes EJ/No
❑ Yes ONo
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes
34. Does the facility require a follow-up visit by the same agency? ❑ Yes
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
r
VNo
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Comments (refer to question ##): Explain any YES answers and/or any additional recommendations or any other comments.
Use drawings of to better explain situations (useadditionatpages as necessary).
IS)- CoA15OCT V-ir H A8ov7 GcZ0Cr 0at.w\.00A ztssC-gyp .g. _.
ASSE -0 wA574L Ant,q6,JSjS "S- 'I (AK , (U95C AOWSSS,
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: C 7
Date:
/4/2 ll

Type of Visit: Qr Compliance Inspection O Operation Review Q Structure Evaluation Q Technical Assistance I
Reason for Visit: Routine O Complaint O Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact:
Arrival Time: Departure Time: County: fl Region:
Title:
Owner Email:
Phone:
Onsite Representative: Cj 6'e Integrator:
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Phone:
Certification Number: a. 19 9
Certification Number:
Longitude:
Design
Swine Capacity
Wean to Finish
Current
Pop.
Wet Poultry
ILayer
Design
Capacity
I
Current
Pop.
Cattle
Dairy Cow
Dairy Calf
Design Current
Capacity Pop.
Wean to Feeder Z,fl
Non -La er
I
Feeder to Finish
Dr, P.ouI
ILayers
Design
Ca aci
Current
P,o ,
Daia Heifer
Farrow to Wean
Farrow to Feeder
Farrow to Finish
D Cow
Non -Dairy
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Other
Other
Turke s
Turkey Poults
Other
Discharges and Stream 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 E�'No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes ❑ o ❑ NA ❑ NE
[:]Yes ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
Page 1 of 3 21412011 Continued

Facility Number: :131 - Date of Inspection: Z/
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes
a. If yes, is waste level into the structural freeboard? ❑ Yes
SttruucturreL 1 Structure 2 Structure 3
Identifier: LA
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): L
�No ❑ NA ❑ NE
❑ No ❑ NA ❑ NE
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 environment"�l threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes No ❑ NA [] NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes No ❑ NA ❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes t,lJ o ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need [:]Yes No ❑ NA ❑ NE
maintenance or improvement?
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?
❑ s
0 No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
Yes
❑ No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
Ej/No
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
VN
❑ 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
[] NIo
❑ NA
❑ NE
the appropriate box.
❑WUP ❑Checklists ❑Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate bybelo ❑ Yes ❑ No ❑ NA ❑ NE
Waste Application ❑ Weekly Freeboard ❑ Waste Analysis Analysis ❑ Waste Transfers ❑ Weather Code
❑Rainfall ❑Stocking ❑ Crop Yield ❑ 120 Minute Inspectionsy and V Rainfall Inspections ❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes No ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes Fz No ❑ NA ❑ NE
Page 2 of 3 21412011 Continued

Facility Number: jDate of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes V�NN ❑ NA ❑ NE
25�Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes ❑ 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 rNo ❑ 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?
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
❑ Yes E No
❑ Yes dNo
❑ Yes ! No
❑NA ONE
❑ NA ❑ NE
❑ NA ❑ NE
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? El Yes ; ❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency? ❑ Yes No ❑ NA ❑ NE
Comments (refer to question ft Explain any YES answers and/or any additional recommendations or any other comments.,
Use drawings of facility to better.explain.situations (use additional pages as necessary):
�') Fiet-5 M6(-p LhAEC50
6k �N a:s1rt_N1 d n/ � � ;!NL iYs , � � 6P� a � $aIL j lr S T= Cyc�'c
J
Swami Gxe'MM&j%
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: " CD
Date: 51111
1
21412011

Division of Water Quality
mu
FaCIltliyNumber' 0 Drvision of=Soiland Water Conservation > �`
O OtherAgeney
Type of Visit (!f7ROutine
pliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: Arrival Time: ® Departure Time: County:Dap Region:
Farm Name: Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Phone:
Facility Contact: Title:
Onsite Representative: J �RJaL _ integrator:
Phone No:
Certified Operator: Operator Certification Number:
Back-up Operator:
Location of Farm:
Back-up Certification Number:
Latitude: = c = 6 Longitude: [= ° =1
Design Current - Desigu Current 2
-. .
Swine " Capacity Population Wet Poultry Capacity Population: Cattle
❑ Wean to Finish ❑ Layer ❑ Dai Cow
Wean to Feeder > ❑ Non -Layer I 1===1�a' ❑ Dairy Calf
❑ Feeder to Finish El El
Heifer
El Farrow to Wean Dry Poultry `' �' El D Cow
fr ❑ Farrow to Feeder ` ❑ N D
❑ Farrow to Finish
❑ Gilts
❑ soars
Other
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ Turkey Pouets
❑ Other
on- a
❑ Beef Stocker
❑ Beef Feeder
r ❑ Beef Brood Co
Number of�Structures
Discharges & Stream impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
❑ Yes tj No []NA ❑ NE
❑ Yes ❑ No
❑ NA
❑ NE
❑ Yes ❑ No
❑ NA
❑ NE
El NA
[I NE
❑Yes ❑N
El Yes LdN
[I NA
❑ NE
El Yes , No
❑ NA
❑ NE
Page 1 of 3 12128104 Continued

Facility Number: 3 1 —Sell Date of Inspection 1 ti
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): 3/
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes
No ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes
ffNo ❑ 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 environment altnotify DWQ
El7. Do any of the structures need maintenance or improvement? Yes
Eleat,
o NA ElNE
8. Do any of the stuctures lack adequate markers as required by the permit? ElYes
�rNo ❑ 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 [I NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need El Yes
E] No ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes
ICJ No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
[--]PAN ❑ PAN > 10% or l0 lbs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window [:]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
E No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
ET/No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
❑ Yes
Ek No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
� o
❑ NA
El NE
18. is there a lack of properly operating waste application equipment?
El Yes
WNo
❑ NA
❑ NE
> � � �.;-� � �:�� Ewa � � <,�� � ,
;Comments (refer to question #} Egplatn-anv YES"answers andlor any,.recomri endati6ns or. any other comments
:.
%Use diawings of Ifacility to'better explain
situations (use additional pages as necessary)
�s ,� F�u� S ��l1Gf Fx EwliYs�
d
LReviePwerlins ector Name
o E '.' Phone: U
Reviewer/inspector Signature: Date: 31 1
Page 2 of 3 .12128104 Continued

Facility Number: — Date of Inspection
Required Records & Documents 1
19.. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes Zo
[I NA El NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes ❑ NA ❑ NE
the appropriate box. ❑ WUp ❑ Checklists ❑ Design El Maps ❑Other
21. Does record keeping need improvement? If yes, the the appropriate box below. E Yes ❑ No El NA ❑ NE
❑ Waste Application Elrd WWeekly Freeboaaste Analysis ❑ Soil -Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V Rain Inspections ❑ Weather Code
22. Did the facility fail to install and maintain a rain gauge?
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
24. Did the facility fail to calibrate waste application equipment as required by the permit?
25. Did the facility fail to conduct a sludge survey as required by the permit?
26. Did the facility fail to have an actively certified operator in charge?
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
and report the mortality rates that were higher than normal?
30. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately
31. Did the facility fail to notify the regional office of emergency situations as required by
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
33. Does facility require a follow-up visit by same agency?
Additional Comments and/or Drawings:
❑ Yes
LSNo
❑ NA
❑ NE
❑ Yes
&No
❑ NA
❑ NE
111�es
❑ No
❑ NA
❑ NE
Wyes
❑ No
❑ NA
❑ NE
El Yes El NA [I NE
❑ Yes L No ❑ NA ❑ NE
❑ Yes L� o
❑ Yes FNNo
❑ Yes hd No
El Yes ON
❑ Yes
❑ Yes No
❑ NA ❑ NE
❑NA ❑NE
❑ NA ❑ NE
El NA El NE
El NA El NE
El NA El NE
Page 3 of 3 12128104

Type of Visit Co pliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit td Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: �_ !j j LJLd J Arrival Time: Departure Time: County: 0UPLZJ Region:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Owner Email:
Phone:
Facility Contact: Title: Phone No:
Onsite Representative: �� Q�a�lc Integrator:
Certified Operator:
Operator Certification Number:
Back-up Operator: Back-up Certification Number:
Location of Farm:
Latitude: = o[= g= u Longitude: 0 0= 4
Swine
M�4..
C*urrent
opulation
Design Current Design Current
Wet Poultry Capacity Population Cattle C**opacity Population
❑ Layer ❑ DairyCow
to Finish
n to Feeder
er to Finish
w to Wean
rn
26
20
❑ Non -Layer
❑ DairyCalf
❑ Dai Heifer
❑ D Cow
w to Feeder
❑ Non
La ers
❑ Non -Layers
❑ Pullets
❑ Turke s
❑Turke Poults
❑Other
-Dairy❑
w to Finish
❑ Beef Stocker
❑ Beef Feeder
❑ Beef Brood Co
❑ Boars
Other
❑ 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 EfNo ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑NA
❑NE
[]Yes
[I Yes
E❑No
VNo
❑ NA
❑NE
❑ Yes
❑ NA
❑ NE
Page I of 3 12128104 Continued

Date of Inspection i
Facility Number:
Waste Collection & Treatment
1
' 4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
0 o ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No ❑ NA ❑ NE
Structure 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
E No ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
❑ Yes
O 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
ron
enviental threat, notify DWQ
7. Do any of the structures need maintenance or improvement?
Yes
❑ No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit?
❑ Yes
ErNo ❑ 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
dNNo ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
O No ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below.
❑ Yes
ONo ❑ 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 NA
El NE
15. Does the receiving crop and/or land application site need improvement?
dyes
Wo❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
❑ Yes
3 NNo ❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
ElYes
L,�d,'No ❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
ElYes
No ❑ NA
❑ NE
Comments (refer to question ft Explain any YES"ansfvers and/or'any:"reeomn endations or any oYtier comments'
Use drawings of facility to better explain situations: (use additional pages as necessary)
-.:
CATI - 9,� WtJ S+v✓>gC. C l.EF.S OM -T►U SIO G O-t3CC " "L1A
,
�S, CaIVT r�tl(.G i.✓vre,IL w�fi� ��S"c vF �.1 C.O. SE �1� w�f
P�Q&T(YJ aV Z01
Reviewer/Inspector Name `Jojhl".
°' g�
Phone:C D %
Reviewer/Inspector Signature: 4 mdADate:
3 t
Page 2 of 3 1 12128104 Condnaed

S
Facility Number: ) -5`1 Date of Inspection ti
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes ENo ❑ 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 ❑Other �/
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ IT Yes No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and F Rain Inspections ❑ Weather Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
❑'No
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
dNo
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
E2-1�o
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
[Ko
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
2N
El NA
El NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
(� No
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
D<o
ElNA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
ElE 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
BINo
❑ 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
❑4-o
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32.
Did Reviewertinspector fail to discuss review/inspection with an on -site representative?
❑ Yes
o
[3NA
ElNE
33.
Does facility require a follow-up visit by same agency?
ElYes
No
❑ NA
❑ NE
Additional Comments and/or Drawings:
Page 3 of 3 12128104

1 H .`7
Type of Visit co pliance Inspection O Operation Review O Structure Evaluation Q Technical Assistance
Reason for Visit CO Routine O Complaint O Follow up O Referral O Emergency O Other ❑ Denied Access
Date of Visit: 6 Arrival Time: 1 ZOb Departure Time: County: 40 Region:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact: Title:
Onsite Representative:
Certified Operator:
Back-up Operator:
Owner Email:
Phone:
Phone No:
Integrator:
Operator Certification Number:
Back-up Certification Number:
Location of Farm: Latitude: = c = 6 = Longitude: = ° = I ❑ "
Design Current
Swine Capacity Population
Design Current
Wet Poultry Capacity Population
Design
Cattle Capacity
Current
Population
❑ Wean to Finish
❑ La er
❑ Dairy Cow
KI Wean to Feeder
❑ Non -La er I
❑ Dairy Calf
❑ Feeder to Finish
❑ Daia Heifer
❑ Farrow to Wean
Dry Poultry
❑ Dry Cow
❑ Farrow to Feeder
❑ Non -Dairy
❑ Farrow to Finish
❑ Layers
❑ Beef Stocker
❑ Gilts
❑ Non -Layers
❑Beef Feeder
❑ Boars
Cl Pullets
❑ Beef Brood Co
❑ Turkeys
Other
❑ Other
❑ Turke Poults
❑ Other L
Number of Structures:
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)?
-71
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
❑ Yes
NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
V�m4lo,
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
LrNo
❑ NA
❑ NE
other than from a discharge?
Page I of 3
12128104
Continued

Facility Number: — Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes jNo ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structur 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): g
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes ONo ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes No ❑ NA ❑ NE
through a waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmentalthr at, notify DWQ
7. Do any of the structures need maintenance or improvement? ElYes �No ❑ NA El NE
8. Do any of the stuctures ,�,
lack adequate markers as required by the permit? ❑ Yes No ❑ NA ❑ NE
(Not applicable to roofed pits, dry stacks and/or wet stacks)
4. Does any part of the waste management system other than the waste structures require ❑ Yes LJ No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
W. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes ;No
N El El NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below, ❑ Yes ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 Ibs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop 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 WNx
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?❑ Yes WNo
❑ NA
❑ NE
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 LJ No
❑ NA
❑ NE
FAX OfC n AW
Reviewer/inspector Name
Reviewer/Inspector Signature:
Page 2 of 3
Phone:
Date:
12127104

Facility Number: $ Date of Inspection 6
Required
Records & Documents
19.
Did the facility fail to have Certificate of Coverage & Permit readily available?
❑ Yes
[� o
ElNA
[INE
20.
Does the facility fail to have all components of the CAWMP readily available? If yes, check
ElYes
No
❑ NA
❑ NE
the appropirate box. ❑ WLTP ❑ Checklists ❑ Design ❑Maps El Other
21.
Does record keeping need improvement? if yes, check the appropriate box below.
E/Yes
❑ No
❑ NA
❑ NE
❑ Waste Appli tion El Weekly Freeboard ❑ Waste Analysis El Soil Analysis [I Waste Transfers
[I Annual
Certification
El Rainfall Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and I"
Rain Inspections ❑
Weather Code
�o
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
;No
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
❑ No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
o
El NA
El 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
[ No
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
El Yes
��//
E2 No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
dNo
❑ 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
EKNo
❑ 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
Oo
❑ 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
�,
[:1 NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
L'J No
❑ NA
❑ NE
Additional Comments and/or, Drawings:- =„
Page 3 of 3 12128104

0 Division of Water Quality 1
r'Facility Number 31, S % Q 0 Division of Soil and Water Conservation 11
- 0 Other Agency
Type of Visit ,Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit V Koutine 0 Complaint 0 Fallow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: Arrival Time: Ob Departure Time: County: I3vPtsAl Region:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact:
Title:
Owner Email:
Phone:
Onsite Representative: `r 0`? 613:�2 411 - ^— Integrator:
Certified Operator:
Phone No:
Operator Certification Number:
Back-up Operator: Back-up Certification Number:
Location of Farm: Latitude: = o = 4 = Longitude: = ° 0 C 0 «
Swine
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Other
❑ Other
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer
Z_o ❑ Non -Layer
Dry Poultry
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turke s
❑ 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 Heifer
❑ Dry Cow
❑ Non -Dairy
❑ Beef Stocket
❑ Beef Feeder
❑ Beef Brood Cowl
Number of Structures:
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
❑ Yes �No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
K
El
❑ NE
ElYes
7wo
❑ NA
❑ NE
12128104 Continued

Facility Number: 3 j — S�`( Date of Inspection I 12S1�o I
Wcaste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes [�No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: t LI6mo"
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): 4194
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes dNo ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes ZNo ❑ NA ❑ NE
through a waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? [,Yes ❑ No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes �No ❑ NA ❑ NE
(Not applicable to roofed pits, dry stacks and/or wet stacks)
4. Does any part of the waste management system other than the waste structures require ❑ Yes E(No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes 6No ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes ONo ❑ 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 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
[Z] No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
ENo
❑ NA
❑ NE
No
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?❑ Yes
❑
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
6
�/7N,o
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
❑ NA
❑ NE
IComments (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):
1L� STtLL iJPV( ANZrv►AL-S 4rGGiNG MJ WA%_�S, D CU^'►CuT t,touc-. Ak
2(.) 50_r _ j�,� Ja v `; JTJ rJ C- D fop__ Zoo f 5 b -�'► w�Tk ro B✓.�tn/E f✓ Qr4 i�J.
Reviewer/Inspector Name ` off J F,Q c o_, Phone: %tv 7116 — 73V
Reviewer/Inspector Signature: Date:
I4/�V/VT I.VLI LLLL f{GN

Facility lumber: 31 — ? Date of Inspection
Required Records & Documents JNo
19. Did the facility fail to have 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 2No ❑ NA ❑ NE
the appropirate box. ❑ WUp ❑ Checklists ❑ Design ❑ Maps ❑ Other
21. Does record keeping need improvement? If yes, check the appropriate bo below. 0 Yes El No El NA El NE
El Waste Application El Weekly Freeboard ❑ Waste Analysis Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rain Inspections ❑ Weather Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
o
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
WNo
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
[(No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
DNo
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
[/2(No
❑ N
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
El Yes
❑ No
NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
CNo
❑ 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?
El Yes
,�,3/
LNo
❑ 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
UNo
❑ 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
IJ No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
No
❑ NA
❑ NE
Comments and/or Drawings:
12128104

Q) Division of Water Quality
a =Fadlityumber 0 Division of Soil and Water Conservation
O Other Agency
r
f Visit Co liance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
n for Visit Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ 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: Phone No:
ISOnsite Representative: �0 1 Integrator•
Certified Operator: Operator Certification Number:
Back-up Operator: Back-up Certification Number:
Location of Farm:
Swine
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Boars
Other
❑ Other
Latitude: 0 0 [� Longitude: [= ° = i = H
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ La er
Zb Non -La ei
Dry Poultry
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ Turkey Poults
❑ Other
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
Design::. Current
Cattle Capacity Population..
❑ Dairy Cow
❑ Dairy Calf
❑ Dairy Heifer
ElDry Cow
❑ Non -Dairy
❑ Beef Stocker
❑ Beef Feeder
❑ Beef Brood Cow
Number of Structures:
�I
b. Did the discharge reach waters of the State? (If yes, notify D WQ)
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 VINo ❑ NA ❑ NE
❑ Yes ❑ No
❑ NA
❑ NE
❑ Yes ❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes ❑
❑ Yes
❑ NA
❑ NE
❑ Yes No
❑ NA
❑ NE
12128104 Continued

Facility Number: — S Date of Inspection 3 6
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes VNo ❑ 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: wo
Structure 5 Structure 6
Spillway?:
Designed Freeboard (in): jq, 5
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes YNo ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
ZNo
ElYes ❑ 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 environ ental threat, notify DWQ
improvement?
7. Do any of the structures need maintenance or
7 Yes
o
El NA
❑ NE
8. Do any of the stuctures 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
ElYes
0/No
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
[/No
❑ NA
❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below.
❑ Yes
WNo
❑ 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)
14, Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
(A No ❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
PNo ❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?❑ Yes
�o ❑ NA
❑ NE
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?
ElYes
LJ No ❑ NA
❑ NE
Comments (refer to question ##): Explain any YES answers and/or any recommendations or any other comments.
Use drawings of facility to better explain situations. (use additional pages as necessary):
7 ) GrwrERS AC66 AJ4i _ 144LES .jr4N
Reviewer/Inspector Name
Reviewer/Inspector Signature:
PE5`t Col-% L, /v6EbE0,
re awa WL"• 1;�"ry 66,0e o r
Phone: A_
Date:
12/2R/OQ
se

Facility Number: 3 L Date of Inspection
r'
Reuuired Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes P4o ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes [�Ao ❑ NA ❑ NE
the appropirate box. ❑ WUp ❑ Checklists ❑ Design El Maps El Other
21.
Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
[3 No
❑ NA
❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V
Rain Inspections ❑
Weather
Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
D<o
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
1:1 Yes
[�To
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
0Yes
❑l No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
2 No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
L'J No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
❑ No
❑.I6
❑ 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
ONo
[]NA
❑ NE
and report the mortality rates that were higher than normal?
�
30.
At the time of the inspection did the facility pose an odor or air quality concem?
ElE Yes
No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
31.
Did the facility fail to notify the regional office of emergency situations as required by
ElYes
�
91, 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
{JNNo
ElNA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
2 o
❑ NA
❑ NE
Comments and/or Drawings:
12128104

V Division of Water Quality
Facility Neiirnber. '� S7 $ 0 Division of. Soil and Water Conservation„-
i
0 Other Agency
Type of Visit (3'Com Ilance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit 0 outine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: a Arrival Time: ® Departure Time: County: 0149LXV Region:
Farm Name: Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact: .. Title:
��
Onsite Representative: � J ° `) +Q" "ice
Certified Operator:
Back-up Operator:
Location of Farm:
0
Latitude:
Phone:
Phone No:
Integrator:
Operator Certification Number:
Back-up Certification Number:
Longitude: = o = 6
Design Current' Design Current :. Design -
Current -'
. Swine Capacity Population Wet Poultry Capacity. Population- -Cattle Capacity ;Population
❑Wean to Finish 1 1 Laver 1 1 F, 10 Dairy Cow
"�' LAJ Wean to Feeder
❑ Feeder to Finish
=' ❑ Farrow to Wean
- ❑ Farrow to Feeder
❑ Farrow to Finish
Boars j
leC
Other
s:.I❑ Non -Layer
Dry Poultry
❑ Layers
ElNon-Layers
ElPullets
ElTurkeys
IE]Turkey Poults
❑ Other
❑ Dairy Heifer
❑ Da Cow
Non -Dairy
❑ 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 I of 3
❑ Yes M No ❑ NA ❑ NE
❑ Yes
❑ No ❑ NA
❑ NE
❑ Yes
❑ No ❑ NA
❑ NE
❑NA
El NE
El Yes
El Yes
VNEl NA
❑NE
ElYes
No ❑ NA
❑ NE
12128104 Continued

Facility Number: 31 — 5�8
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: LA&d'W
Spillway?:
Designed Freeboard (in): 1 .s
Observed Freeboard (in): 'Xi
5. Are there any immediate threats to the integrity of any of the structures observed?
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
through a waste management or closure plan?
❑ Yes No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
❑ Yes No ElNA ElNE
❑Yes 2ZNo El NA El NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental thr t, notify DWQ
7. Do any of the structures need maintenance or improvement? ElYesZo
❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes ❑ NA ❑ NE
(Not applicable to roofed pits, dry stacks and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes Ej No ❑ NA ❑ NE
maintenance or improvement?
Waste Ann ication
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes Ko ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes L! No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 Ibs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
12. Crop type(s) r6s GVG C 6r J
13. Soil type(s) ro A
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
C]fN ❑ NA
El NE
15. Does the receiving crop and/or land application site need improvement?
El Yes
No ❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
❑ Yes
11
Vo ❑ NA
❑ NE
I
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
YNo❑ NA
❑ NE
Comments (refer to question ##): Explain any YES answers and/or any recommendations: or any other 'comments..,-.
Use drawings of facility to better explain situations. (use additional pages as necessary):
lZEt-°R-DS AN9 �grt,.yv�
�,,J (,-aoD Sli�p�, CFESuJE. Q,ESEE,OE�>
Reviewer/Inspector Name --^�
�oN tj �AR,tij (zvt t� -]Phone: t!a 7R6 124S
Reviewer/Inspector Signature:
Date: i b
Page 2 of 3 12128104 Continued

Facility Number: 3 1 —§" Date of Inspection I LJSloio I
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available?
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
the appropriate box.
❑ WUP ❑Checklists ❑Design ❑Maps ❑Other
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 V Rain Inspections ❑ Weather Cade
❑ Yes QrNo ❑ NA ❑ NE
❑ Yes [�No ❑ NA ❑ NE
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes L9 No ❑ NA ❑ NE
23. if selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
Lf No
❑ NA
❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
❑ No
E
1NA
El NE
25. Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
[I No
❑ NE
26. Did the facility fail to have an actively certified operator in charge?
❑ Yes
u No
El NE
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
El Yes
[I No
VN
❑ NE
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
ElYes
rNO
LJ
❑ NA
❑ NE
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
ffNo
❑ 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
,_
E, 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
,�/
L7 No
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
<
❑ NA
[I NE
33. Does facility require a follow-up visit by same agency?
El Yes
7MO
❑ NA
❑ NE
Additional Comments and/or Drawings:
Page 3 of 3 12128104

1
Type of Visit A Compliance inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit JO Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date /�
Date of Visit: ! O Arrival Time: 3S Departure Time: ,r ounty: Region: 4VAV
Farm Name: yA91_A 0 V[ 9r'`t< /e./62/ Owner Email:
Owner Name: d &� &40Q�K Phone:
Mailing Address:
Physical Address:
Facility Contact: Title:
Onsite Representative: _ GrsSFLG �'AfoG► k
Certified Operator:
Back-up Operator:
Location of Farm:
Swine
Wean to Finish
U Feeder to Finish
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
Other
❑ Other
2 _ Phone No:
Integrator• DcrJiJs
Operator Certification Number:
Back-up Certification Number:
Latitude: = O = 6 Longitude: = o = i = «
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer
2EQ 1 ii3 ❑ Non -La et
Dry Poultry
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ Turkey Poults
❑ Other
Discharges & Stream impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ' ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
Design Current
Cattle Capacity Population
❑ Dairy Cow
❑ Dairy Calf
❑ Dairy Heifei
❑ Dry Cow
❑ Non -Dairy
❑ Beef Stocket
❑ Beef Feeder
❑ Beef Brood Co
Number of Structures:
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
❑ Yes 0 No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
0No
❑ NA
❑ NE
❑ Yes
0 No
❑ NA
❑ NE
12128104 Continued

! . �.
Facility Number: p
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?
St cture I Structure 2
Identifier:
Spillway?: LVD
Designed Freeboard (in): „J
Observed Freeboard (in):
Structure 3 Structure 4
❑ Yes A No
❑ Yes ❑ No
Structure 5
❑ NA ❑ NE
El NA El NE
Structure 6
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes No ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes No ❑ NA ❑ NE
through a waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any oft ' he structures need maintenance or improvement? XYes ❑ No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes J9 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 ElNA ❑ NE
maintenance or improvement? fd
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes No ElNA ElNE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes ;A 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) A
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
0 No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
fZ No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination:
❑ Yes
;3 No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
R1 No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
�2 No
❑ NA
❑ NE
i t�-d-7
us�1 ('a.✓7�L
ee J6 C-'fZ7.oai-1
e A --
CORD s `V =`fA %s I�,D �l�D�,�c ja17' , r*1 eL,010 OIZO�P,
Reviewer/Inspector Name ' F Phone: a- ` tl
Reviewer/Inspector Signature: Date: Q
12.128&04 Continued

,' . i.
Facility Number: — Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes No ❑ NA ❑ NE
the appropiate box. ❑ WUP ❑ Checklists ❑ Design ❑ Maps ❑ Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and I" Rain Inspections ❑ Weather Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
No
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
No
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
X'o
❑ 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
/❑ No
❑ NE
Other Issues
IZNA
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
❑ NA
ElNE
if yes, contact a regional Air Quality representative immediately57No
31.
Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
No
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
VNo
❑ NA
❑ NE
Aclditional'Cotnments and/or Drawings: r . .. 4
12128104

� y vuaca ragcuay � �
Type of Visit A Compliance Inspection Q Operation Review Q Lagoon Evaluation
Reason for Visit 11dRoutine Q Complaint Q Follow up 0 Emergency Notification Q Other ❑ Denied Access
Facility Number
Date of Visit: Time:
'f
Not O erational C Below Threshold
7mitted�er tified [a Conditionally Certified Registered Date Last Operated or Above . eshold: ..__.- __. ..
!W Farm Name: - - - - - County: _...QL�....._ ... ..._._ ........
Owner Name: ..._............_ ..... �_...................................... - Phone No: .................. .....
_........................ ......_....... .
MailingAddress: _............ _.. ........_._._... _._._...... ... _ _ .._....W.... _.....
Facility Contact: ........... ........................ Title: _. -- - - - - - - Phone No: .... ....... .................................
Onsite Representative: _ � - f ...J ..... Integrator: ... R N ...
Certified Operator:
Location of Farm:
Operator Certification Number:.......... ......................... ...
❑ Swine ❑ Poultry ❑ Cattle ❑ Horse Latitude ' 4 66 Longitude ' 4 64
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes o
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made'? ❑ Yes ❑ No
b. If discharge is observed, did it reach Water of the State? (If yes, notify DWQ) ❑ Yes ❑ No
c. If discharge is observed, what is the estimated flow in gal/min?
d. Does discharge bypass a lagoon system? (If yes, notify DWQ) ❑ Yes W0--2. Is there evidence of past discharge from any part of the operation? [] Yes
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes o
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ElSpillway ❑ Yes o
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: ....-- T1.- ............ ..............
Freeboard (inches): 36
12112103 Continued

Facility dumber: — Date of Inspection
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, El Yes ONo
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or ❑ Yes ONo
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 maintenancelimprovement? Yes ❑ N
8. Does any part of the waste management system other than waste structures require maintenance!improvement? ❑ Yesr4ol
o
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level ❑ Yes
elevation markings?
Waste Application
10. Are there any buffers that need maintenancetimprovement? ❑ Yes o�
11. is there evidence of over application? If yes, check the appropriate box below. ❑ Yes
❑ Excessive Ponding [] PAN El Hydraulic Overload ❑ Frozen Ground [I Copper and/or Zinc
12. Crop type V65CUF_-" (& L
i
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)?
❑ Yes
ON
14. a) Does the facility lack adequate acreage for land application?
ElYes
b) Does the facility need a wettable acre determination?
❑ Yes
7No,
c) This facility is pended for a wettable acre determination?
❑ Yes
15. Does the receiving crop need improvement?
❑ Yes
o
16. Is there a lack of adequate waste application equipment?
❑ Yes
�/
QNo
Odor Issues
17. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below ❑ Yes 2 Co
liquid level of lagoon or storage pond with no agitation?
18. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes
19. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt, ❑ Yes N
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 No
Air Quality representative immediately.
❑ Field Copy ❑ Final Notes
-7) NCEP 16 CIAK SMALL V-66 OA+ ad=C- ak(:) AdP Eg"6S
Ovxp- ACICE Wriu� .
4G'tuvy � G -o pgxg
Reviewer/Inspector Name
Reviewer/Inspector Signature:
Date:
1.411.41W t1unun9w"

Facility Number: 3 T 7�17 Date of Inspection
Required Records & Documents
21. Fail to have Certificate of Coverage & General Permit or other Permit readily available? ❑ Yes dNo
22_ Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.) ❑ Yes ONo
23. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes 31G
❑ 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
25. Did the facility fail to have a actively certified operator in charge? ❑ Yes No
26. Fail to notify regional DWQ of emergency situations as required by General Permit?
(ie/ discharge, freeboard problems, over application) ❑ Yes No
27. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative? ElYes�No
28. Does facility require a follow-up visit by same agency? ❑ Yes � o0
29. Were any additional problems noted which cause noncompliance of the Certified AWMP? ❑ Yes L
NTPDES Permitted Facilities
30. Is the facility covered under a NPDES Permit? (If no, skip questions 31-35) ❑ Yes o
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 ❑ Crop Yield Form ❑ Rainfall ❑ inspection After V Rain
❑ 120 Minute Inspections ❑ Annual Certification Form
12112103

r
1 �}/ivtsion of Wa_ ter Q .uality � S
Q Dtvtsion of Soil and Water Conservation
•C'.=iiu= "vyx
O
Type of Visit ompliance Inspection Q Operation Review Q Lagoon Evaluation
Reason for Visit Routine Q Complaint Q Follow up Q Emergency Notification O Other ❑ Denied Access
I Facility Number 3 I
Date of Visit: (Q—'� l`�� Time: Fq D CJ Printed on: 7/2i12000
Q Not Operational Q Below Threshold
ermitted Certified © Conditionally Certified © Registered
Farm Name: .. (� ti r 1" r i cr/........._� rvG F_ F
Owner Name: ............ ......
Facility Contact: .......M1.'J��! OG ....Title:. ........................
Mailing Address: ...................................
Onsite Representative: 13"o'C
...............................
Certified Operator: .....---.........
Location of Farm:
Date Last Operated or Above Threshold: .........................
Coantv:..._�V O�. ���............�'v.i.!'..S,t............
Phone No: .. ......................
Phone No: +)v zciK + y)6
........................................................................... ..........................
• Yt C�� i • --�
Integrator:arc ---.•-•----•`-+� -S r
..... Operator Certification tiumber-
U/5wine ❑ Poultry ❑ Cattle ❑ Horse Latitude Longitude
r Design Current Design Current Design Current
Swine Capacity Population Poultry Capacity Population Cattle Capacity Population
Wean to Feeder 10 Layer ❑ Dairy
❑ Feeder to Finish JO Non -Layer I j JO Non -Dairy
❑ Farrow to Wean
❑ Farrow to Feeder ❑ Other
❑ Farrow to Finish Total Design Capacity
❑ Gilts
❑ Boars Total SSLW
Number of Lagoons ❑ Subsurface Drains Present 110 Lags -n Area Io Spray Field Area
Holding Ponds I Solid Traps 10 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 ❑ No
h. If discharge i observed, did it reach Water of the State'' (If yes, notify DWQ) El Yes ONO
c. li' discharge is observed. what is the estimated flow in gal/aun?
d. Does discharge bypass a lagoon system'? (If yes, notify DWQ) ❑ Yes ❑ No
2. Is there evidence of past discharge from any part of the operation? ❑ Yes �No
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes 111-No
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway [:]Yes KNo
Structure I Structure 2 Structure Structure 4 Structure 5 Structure 6
Identifier......................................................................... ..........
Freeboard (inches): 3
5100 Continued on back

Facility Number: —J Date of Iyspection t`rJ-3
FZM Printed ono- 7/21/2000
Y,5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion,
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or
closure plan?
(If any of questions 4-6 was answered yes, and the situation poses an
immediate public health or environmental threat, notify DWQ)
T Do any of the structures need maintenance/improvement?
8. Does any part of the waste management system other than waste structures require main tenance/improvement?
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings?
Waste application
10. Are there any buffers that need maintenance/improvement?
11. Is there evidence of over application? ❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload
12. Crop type
V-4
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)?
14. a) Does the facility lack adequate acreage for land application?
b) Does the facility need a wettable acre determination?
c) This facility is pended for a wettable acre determination?
15. Does the receiving crop need improvement?
16. Is there a lack of adequate waste application equipment?
Re uired 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? (ie/ 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?
(ie/ discharge, freeboard problems, over application)
23. Did Reviewedinspector 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?
0..."Rio'OA' hti<Qns;oi-• 4eiciencje5 Were noted- ditcirig �his;visit. - .0ir will -receive iio further
toriesporidence: abot' f this visit' • ::::::::::: : ::: :
❑ Yes �No
❑ Yes KNo
Comments (refer to question #): Explain any YES answers and/or any recommendations or any. other comments.
Use drawings of facility to betterexplainsituations. (use additional pages as necessary):
Yes ❑ No
❑ Yes 00
❑ Yes TXNo
❑ Yes KNo
❑ Yes o
❑ Yes XNo
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes KNo .
[] Yes r 0
❑ Yes rNo
Yes io
❑ Yes o
❑ Yes o
❑ Yes o
❑ Yes Wo
❑ Yes - No
❑ Yes ii/No
❑ Yes No
IV
Reviewer/Inspector Name
Reviewer/InspectorSignature: 1fZW"10 Date: J6/31/61y 5100

Fi�cifity Number: —5 Date of Inspection G--11.03 Printed on: 7/21/2000
Odor Issues
26. Does the discharge pipe from the confinement building to the storage pond or Iagoon fail to discharge Wor below ❑ Yes 10'
liquid level of lagoon or storage pond with no agitation? X
27. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes 'KNo
28. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt, ❑ Yes o
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 �&o
30. Were any major maintenance problems with the ventilation fan(s) noted? (i.e. broken fan belts, missing or
or broken fan blade(s), inoperable shutters, etc.) ❑ Yes ENO
31. Do the animals feed storage bins fail to have appropriate cover? []Yes 9-INo
5/00

Facility Number '7 Date of Inspection 1171T
Time of Inspection ® 24 hr. (hh:mm)
© Permitted IN Certified © Conditionally Certified [3 Registered 113 Not O erational] Date Last Operated:
Farm Name: ..t.I1Gk> asr........ le.r. .*........ FCounty: ........ �tM..I........ I ..................
Owner Name: ..S,� O.-lain 4............................. B.1'aa,........................................._.... Phone No: ...I «).....%..r... t.itoi....................................
Facility Contact: .4iA.C.l .-A ................ ,.................. Title:...... .................................... Phone No: ...................................................
Mailing Address:..
Onsite Representative:.. . .................... l.Lk...........................
Certified Operator:...1V'g4.11.......... �-
Location. of Farm:
Integrator:........ A.aL� ...............
Operator Certification Number:......
Latitude �' �° �� Longitude
Swine
Design Current _ Desiigii " °Current Design Current
lation _-Poult
CapaciPopu�ao':CCa�acity PopulationCa Capacity Po u
�$ Wean to Feeder
20
❑ Feeder to Finish
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts,
❑ Boars
NuEnber of:Lagooiis :, ❑ Subsurface Drains Present Irl Lagoon Area 10Spray Field Area
Holding Ponds / Solid.Traps ❑ No Liquid Waste Management System
Discharges & Stream Impact~
1. Is any discharge observed from any part of the operation? ❑ Yes RNo
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made? ❑ Yes [KNo
b. If discharge is observed, did it reach Water of the State? (If yes, notify DWQ) ❑ Yes ® No
c. If discharge is observed. what is the estimated flow in gal/min? N k
d. Does discharge bypass a lagoon system'? (If yes, notify DWQ) ❑ Yes W No
2. Is there evidence of past discharge from any part of the operation? ❑ Yes ® No
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes ® No
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway ❑ Yes LK No
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Freeboard(inches): .......2. �....................... ............................ .............................. ...... .... I ................... ..................... ...................... ......................................
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, ❑ Yes 2K No
seepage, etc.)
3/23/99 Continued on back

Facility Number: 31 Date of Inspection j(ri--Q.
it
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or
closure plan? ❑ Yes DQ No
(If any of questions 4-6 was answered yes, and the situation poses an
immediate public health or environmental threat, notify DWQ)
7. Do any of the structures need maintenance/improvement? ® Yes ❑ No
8. Does any part of the waste management system other than waste structures require maintenarice/improvement? ❑ Yes [A No
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings? ❑ Yes ®No
Waste Armlication
10.
Are there any buffers that need maintenance/improvement?
❑ Yes
R) No
11.
Is there evidence of over application? ❑ Excessive Ponding ❑ PAN
❑ Yes
® No
12.
Crop type G
13.
Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)?
❑ Yes
29 No
14.
a) Does the facility lack adequate acreage for land application?
❑ Yes
QQNo
b) Does the facility need a wettable acre determination?
❑ Yes
K 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?
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?
❑ Yes K No
❑ Yes 0? No
(ie/ WUP, checklists, design, maps, etc.)
❑ Yes
R No
19.
Does record keeping need improvement? (ie/ irrigation, freeboard, waste analysis & soil sample reports)
Yes
❑ No
20.
Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
CK No
21.
Did the facility fail to have a actively certified operator in charge?
❑ Yes
No
22.
Fail to notify regional DWQ of emergency situations as required by General Permit?
(ie/ discharge, freeboard problems, over application)
❑ Yes
No
23.
Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes
K No
24.
Does facility require a follow-up visit by same agency?
❑ Yes
M No
25. Were any additional problems noted which cause noncompliance of the Certified AWMP?
0: N-0,A6taiioris or defcieucies were pQted• during this:visit: • Yoit will•feeeive iio fui-ther
corres�ancieDec. about this visit. . . .... ... ... • • • .......
❑ Yes [RNo
Comments (Fefer,to `question 4 'Explain any; YES answers and/or an recommendations or:ao other. comments:- =
Y y,_ -
Use_dfawinga of facility to _better explain?situations (use additional pages as necessary) -
T !Flow iKxr e v 1 eWr Ai lC a watts ,
15. Wont pr► ;Ax?ror►rj '�rscwc Co-op k -Pie IA *y . Ay nGcoL-1q. U.pda4-e- Soil ArrnoLty s 5.
l�pa� C�aSurt- PIAn is
t�. rr.cards, Cbld
lrt
Z
/Vp
Plans � rr -s•#x. k �.. a cou�lr o� w:�ks.
i
Reviewer/Inspector Name t7,7
�-
Reviewer/Inspector Signaturev' 2V k; e r /DWON Date:
(71O}.3qs-39dU 3/23/99

Facility Number: 3 — Date of Inspection
Odor Issues
26. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below Q9 Yes rNo
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes QA No
28. is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt, ❑ Yes A 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 Le No
30. Were any major maintenance problems with the ventilation fan(s) noted? (i.e. broken fan belts, missing or
or broken fan blade(s), inoperable shutters, etc.) ❑ Yes ($No
31. Do the animals feed storage bins fail to have appropriate cover? ❑ Yes K No
32. Do the flush tanks lack a submerged fill pipe or a permanent/temporary cover? ❑ Yes LK No
[Additional Comments and/or Drawmgs- -
3/23/99

❑ Division of Soil and Water Conservation ❑ Other Agency
0 Division of Water Quality
Routine 0 Complaint 0 Follow-ue of DW2 inspection 0 Follow-up of DSWC review 0 Other
Date of Inspection I3 q g
Facility Number
Time of Inspection f , 1� 24 hr. (hh:mm)
© Registered 13 Certified 0 Applied for Permit 0 Permitted 10 Not Opera Date Last Operated:
Farm Name: liar&& A...... L'L<....r6d:t?.............................. County: ......... �L�11x%................................... .
Owner Name: ........ ��.�..... �. .................... Phone No: ....... L`�..�..� %6..::.JkP.I.....................................
.................... ..... ................ .......
Facility Contact: .............................................................................. Title:............. Phone No:
k ...... Mailing Address:..... Z.i, 0$..---.i
-��6ar..11� .......: .......................................................... �t�lA.x.��,��---••t..IJ.L.................................. ...n.51,&
Onsite Representative: ........... 6AX.L4 A ..... &ALL .................................................. Integrator: ....... &.Qwas.................................
Certified Operator;............................................................................................................... Operator Certification Number;
Location of Farm:
.............PA%......"r........$ I &....4.�.......` L.....1.9.G.i.r...�C? :..5....ta.►l i s.....t?.r1� ..... :... .1`i.S. .,c.. ...... .... F
.. --------------- .. -------...---.--....-----....-- ...I................----- .. ......
Latitude 0•=' " Longitude =• =' ="
I?estgn Current
Desiga Current ` a Desrgn = Currept
Svwune c Capacity Population Poultry
Capacity Populattan Cattle Calractty PopuiaEion r'
-: EaWean to Feeder -27o ❑ Layer
❑ Dairy
❑ Feeder to Finish ❑ Non -layer
JE1 Nan -Dairy¢
❑ Farrow to Wean
❑ Other
Rom.' ❑ Farrow to Feeder
❑ Farrow to Finish
Toga] Design CapaCzcy ,
❑ Gilts
❑Boars
1h, Total SSLW.:
N
I0Subsurface
Drains Present
❑Lagoon Area
IDSpray Feld Area
❑ No Liquid Waste Management System
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
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a.' If discharge is observed, was the conveyance man-made? ❑ Yes [� No
b. If discharge is observed, did it reach Surface Water? (If 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 yes, notify DWQ) ❑ Yes [P No
3. Is there evidence of past discharge from any part of the operation? ❑ Yes 0 No
4. Were there any adverse impacts to the waters of the State other than from a discharge? ❑ Yes V3 No
5. Does any part of the waste management system (other than lagoons/holding ponds) require ❑ Yes q No
maintenance/improvement?
6. Is facility not in compliance with any applicable setback criteria in effect at the time of design? ❑ Yes CP No
7. Did the facility fail to have a certified operator in responsible charge? ❑ Yes 0 No
7/25/97

FisoMty Number: 3 S-?
8.
Are there lagoons or storage ponds on site which need to be properly closed?
Yes
❑ No
Structures La oons oldin Ponds Flush Pits etc.
9.
Is storage capacity (freeboard plus storm storage) less than adequate?
5(Yes
❑ No
Structure I Structure 2 Structure 3 Structure 4
Structure 5 Structure 6
Identifier: z............................................................................
................................... .......................
.........
Freeboard(ft): ....................................................................................................................................................
10.
Is seepage observed from any of the structures?
❑ Yes
[SNo
11.
is erosion, or any other threats to the integrity of any of the structures observed?
❑ Yes
® No
12.
Do any of the structures need maintenance/improvement?
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
q No
Waste Annlication
14. Is there physical evidence of over application? ❑ Yes (9 No
(If in excess of WMP, or runoff entering waters of the State, notify DWQ)
15. Crop type....................tf,So1.1.....................................................................................................................................................................................................
16. Do the receiving crops differ with those designated in the Animal Waste Management Plan (AWW)?
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 review/inspection with on -site representative?
22. Does record keeping need improvement?
For Certified or Permitted Facilities Only
23. Does 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?
25. Were any additional problems noted which cause noncompliance of the Permit?
[3-No.vi61a'tionssor. deficiencies.were-noted-nudng this.visit'.-You:will rec_eive,no,f iriher-:
correspbtidepce A;otit this'vWt , ;
❑ Yes E3 No
❑ Yes ® No
R1 Yes ❑ No
❑ Yes 51 No
Yes ❑ No
❑.Yes 10 No
14 Yes ❑ No
❑ Yes P No
M Yes ❑ No
® Yes ❑ No
Mr. Y>rvc,k ks 4 +(,4- race$Sof dos;vt3 oId Icwp,. bras Lot e!,4A lt.5j 0,4
�a JaGr� s ref r u,� e ous once InaS V -ir, Wa
q. ��sv c►u irt-C�r�r� ;r. A (c, oan• Tt�s 65cen 5ka�t� be ea►np�,��ctY CAOSJ oc�
.0 s 0055 i W
12 - 7,1Ct W'k% o E r� S �,ot<2� b2 I'�4W t�, !� 1 ` t I f 1 �f CAI
is. i"e�cu� CYb�a WiUS �a ins yD�fe(� 1r1 �r�tl oi- ki�_
Sa ,d � < �5 to rJk �n iuU T+��S #�!i
Ccobig roc. � �f [�a�ttr �11 CX forp je n/tte I�=r �S ,
b� ab��o Q.X4tnnd ci+� �i,r S � kJ,:nt
A�.0�
So-1 °i' O-S SaW. lt5 S4tOLJ` f�c v C-Icl1l+U r ` 11 ii 5
L1.1zs. W._- War, a,\c%U 4e �r&S 1101 �A WI)4�. rj4CIAC s�ojb &e Cjae�i b nian orU�SCnni17n2Jeg7 •
N
Reviewer/Inspector Signature: 7' IL_ /,-, l Date:

I
X DSWC Animal Feedlot Operation Review
k4,
DWQ Animal Feedlot Operation Site Inspection
Utm-
Routine O Con3 faint Q Follow-u of MV ins ection O l' ollow-u of DSWC review Q Other
Date of Inspection
Facility Number `i +
Time of Inspection : 5b 24 hr. (hh:mm)
® Registered ©Certified ©Applied for Permit [3Permitted ©Not O erational I Date Last Operated:
Farm Name:... er-.L.�-�--�- R.Y-?..=-:.... "'�'"�- County:.... .v.{p.. .4. ^.......[...................... ^.-.{� .,...
Owner Name:...... -vim rY` .�...........�..YA..f� .. Phone \o .. ..�.lfl... .........q..t?...........6 .....L..................
FacilityContact: .............................................................................. Title:................. ........
Phone No: ...................................................
TMailing Address:
.... 2 ...01....... Aa ... ! 1-&-v' ..1.1su......P.:..........................$...... .,..t...t.1.e,.t...r�.i.. ...............Z.x.5..�.
Onsite Representative:.... X'a^�.� ^. ........«........................... Integrator:.....-dj..! y�,l..±^ri........... ......................................
...........I Operator Certification Number;.......1....��,�......-.....
Certified Operator; ....................................................
Location of Farm:
p.1 a.....X4.lt.c �a.i.$d.. ..S.1.t�.R ....4...... �.....p„ . 1!D. %.,�!!�a . ........�..:.,�.....?i!rn e. i.R r�.......,ea.,v..� ! S F,-�t.d.�`":....... A
s�..Q...-.. ... ...... ........................ ......---....... ... .....
Latitude ' 1 cc Longitude • ` ="
Design . Current Design Current Design Current
sw'meCapacity Population Poultry Capacity Population Cattle: Capacity Population
❑ Wean to Feeder ❑ Layer' ❑ Dairy
❑ Feeder to Finish JE3 Non -Layer JE1 Non -Dairy
❑ Farrow to Wean
❑ Farrow to Feeder 10 Other
❑ Farrow to Finish Total Design Capacity
❑ Gilts
❑ Boars Total SSLW
Number of Lagoons / Holding Ponds. Subsurface Drains Present ❑ Lagoon Area lErSpray Field Area
❑ No Liquid Waste Management System
General
1. Are there any buffers that need maintenance/improvement? ❑ Yes K No
2. Is any discharge observed from any part of the operation? ❑ Yes No
Discharge originated al: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made? ❑ Yes ® No
b. If discharge is observed, did it reach Surface Water" (If yes, notify DWQ) ❑ Yes ® No
c. If disch; r� e i,, observed, what is the estimated flow in--dhnin?
d. Does discharge bypass a lagoon system? (If yes, notify DWQ) ❑ Yes JR No
3. Is there evidence of past discharge from any part of the operation? ® Yes 99 No
4. Were there any adverse impacts to the waters of the State other than from a discharge? ❑ Yes 19 No
5. Does any part of the waste management system (other than lagoons/holding ponds) require ❑ Yes ® No
maintenance/improvement?
b. Is facility not in compliance with any applicable setback criteria in effect at the time of design? ❑ Yes C4 No
7. Did the facility fail to have a certified operator in responsible charge? ❑ Yes M No
7/25/97 Continued on back

t
Facility Number:
8. Are there lagoons or storage ponds on site which need to be properly dosed?
Structures (Lagoons,Holding Ponds, Flush Pits, etc.}
9. Is storage capacity (freeboard plus storm storage) less than adequate?
Structure I Structure. 2 Structure 3
Identifier:-........J..,...I...
Freeboard (ft):..........L,... `.j................ ........ .0.,...�..�.r............ ...
..........................
10. Is seepage observed from any of the structures?
Structure 4
91 Yes ❑ No
R Yes ❑ No
Structure Structure
................................................................................................................
❑ Yes KNo
It. is erosion, or any other threats to the integrity of any of the structures observed?
12, Do any of the structures need maintenance/improvement?
' (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?
Waste Application
14. Is there physical evidence of over application?
(If in excess of WMP, or runoff entering waters of the State, notify DWQ)
5. Crop type u�^.i................................................................................................ ..
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 review/inspection with on -site representative?
22. Does record keeping need improvement?
For Certified or Permitted Facilities Only
23. Does 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?
25. Were any additional problems noted which cause noncompliance of the Permit?
0, No violations-4 defeieneies.were noted during this.visit. You.will receive no further
correspondence about this.visit.-. _
❑ Yes ® No
E Yes ❑ No
O[Yes ❑ No
❑ Yes 0 No
.....................................
IR Yes ❑ No
❑ Yes 19 No
❑ Yes No
1K Yes ❑ No
® Yes ❑ No
❑ Yes UNo
19Yes ❑ No
❑ Yes 91 No
❑ Yes ® No
❑ Yes ;FI-No
Cottunents (refer to' question #) Explatn any YES answers and/or any recommendations or any other comments:
Use'drawings of facil€Ey:to<better, explain sttuatttins (use additional pages as necessary}
Qk
.4f �� ti► p.l� s t'Vy L 4 _ 1 S TO r,ol f �. 1
+4 a (i -0-.� d rwk i +.� , �^ „-a yvk cL � a,..,,,� i,� 4o-..L � �41 a �f
S w N•�. �1. + j L l {w 0. i'1 O n d K o v G r v.� C (�R ti w, w�2at 1 QLJ�e.�y
S o ti �a1 �, o �Jl s 1--o w I J % e q ,• 4 p a ,r �j L t c .! tAL a v t a •r
d-
1, A -a n+ I b 6 LL t M �-� LIPa l-e . yr u !a
r u �l , i w a d d, I-r L , �- . L o o-�v�,[ ; s 3 e i- t--'l a w �-o r �
'i`L• e s ¢. z 00 s s ka v b� ,.vim-a-� �' t v� t
L 4 a Lt 10 a *-� w r-e.c� i o ,1 l o g r o w a l l '` t" "` fV-C 1`C'It
Ulu;
v ;
�1�kit , r'"t �t<�'�r6�-, o,.4V.Wu[1 .Nti.R.v.21�.. 7/25/97
_..::.. 7
ReviewerlInspector Name , _ [
Reviewer/Inspector Signature: r Date: -7

. FaeilAy Number:.. .1, ... -...i Date of Inspeetion: to -7 q
Additional Conufients and/or Drawings.
1 b L ro SF Gad r qq via i n- L, S k, L es 1 r.i kA4 a-C 4
CR."
la_C C-OL Cc- v I-eL o f ,r a
w; h,
t
bV�r'�-�.tl-tN i � CJ� p � � 4 Q ✓1 .
4/30/97

Site Requires Immediate Attention:
' Facility No.
DIVISION OF ENVIRONMENTAL MANAGEMENT ,
ANIMAL FEEDLOT OPERATIONS SITE VISITATION RECORD
DATE: _a , 1995
Time: % 9 Li D
Farm Name/Owns
Mailing Address:
County
Integrator: �6 C 0 arl D _ Phone:
On Site Representative: , %4,. lets. c-0—re-) ��� Phone: ye
Physical Address/Location: W im 4- 9 6 r ci v 0,
—fir- .:jr' ._ e
Type of Operation: Swine. '� Poultry Cattleu -� I
Design Capacity: _ rah.a Number of Animals on Site: col d C-
DEM Certification Number: ACE DEM Certification Number: ACNEW
Latitude: " L" Longitude: 77 Elevation: Feet
Circle Yes or No
Does the Animal Waste Lagoon have sufficient freeboard of 1 Foot + 25 year 24 hour storm event
(approximately I Foot + 7- inches) Y2 or No Actual Freeboard: J Ft. Inches
Was any seepage observed from the lagoon(s)? Yes 06 Was any erosion observed? Yes of�a
Is adequate land availablefor spray? Yes or No Is the cover crop adequate? Yes or No
Crop(s) being utilized: /,/�,')-paten
Does the facility meet SCS minimum setback criteria? 200 Feet from Dwellings?&� or No
100 Feet from Wells? e� or No
Is the animal waste stockpiled within 100 Feet of USGS Blue Line Stream? Yes or No
Is animal waste land applied or spray irrigated within 25 Feet of a USGS Map Blue Line? Yes or No
Is animal waste discharged into waters of the state by man-made ditch, flushing system, or other
similar man-made devices? Yes 0 If Yes, Please Explain_
Does the facility maintain adequate waste management records (volumes of manure, land applied,
spray irrigated on specific acreage with cover crop)? Yes or No
Additional Comments: A) W l Jecljykia� 2i=O�-r-t ca
Inspector Name Signature
cc: Facility Assessment Unit Use Attachments if Needed.

Site Requires Immediate Auention:
} Facility No. �1
DIVISION OF EIN IRON-NMNTAL MAINAGEMEINT
A__,SAL FEEDLOT OPERATIONS SITE VISITATION RECORD
DATE: - it . , 1996,
Time: _ Z'10,e
Fa_-,n Name/Owner:
IaihnE Address: 2i o � � %/S
County: e { -� ^ _
Inte?i at�r: mod r�yrZ O"- r A 2OkAJA Phone:
Or= Site Representative: Phone:
Ph, sical Address/Locatian: 2 (,,g %, l,P_ ,ate rnx, O • LS: A421A �eo� _
S r� <-_3
Ty-pe. of Operation: Swine Poulty Canle
Design Capacity: Number or Animals on Site:
DELI Certification Number: ACE DEM Certification Number: ACNEW
Larrude: ° ' „ Lon,?ra:Ie: ° ` " Elevation: Feet
Circle Yes or No
Does the Anibal Waste Lagoon have sufficient freeboard of 1 Foot - 25 year'?_A hour store event
(approximately 1 Foot T 7 inches) Yes o -o Actual Freeboard: Ft. #-W&Inclies
Was a y seepage observed from the lagoon(s)? Y is ord52 as any erosion observed? r No
iis adeouate land available for sprav? j Vor -No Is the cover crop adequate? Ycs o
Crops) being util,==zed: rrK4.ri 1�445 c� Ark �FA�lZS —�
Does the faci.iity meet SCS minimum setbackk i.�:teria? 200 Feet ftoin Dwe I:n2s or No `
100 Feet from W'elis? or N-'o
Is the animal waste stockpiled within 100 Fee: of USGS Blue Line Siie=, Yes 0110
Is -nima-1 waste 1a.nd applied or spray irrigated within 25 Feet of a USGS Nlap Blue Lire? Yes oil
Is ai.irial waste discharged into waters Of the stale by man-made ditch; fluff Li;PG 5vste1:11. Or OCiie:
similar man-made devices? Yes 70 If Yes, Please F�plain.
Does the facility maintain adequate -waste iLanagement records (volumes of manure, ia:,cl aupiied,
spray irrigated on specific acreage with cover crop)? Yes or�
A ,ldid/
onal Coi=ents: 4 �c T An
_), fch . Ny 510 ��
�vA, /a h lc Via. ��.�: - t Avo
in,occtor Name S:riatilre
cc: Facility Assessmerii Uni[ T

SEATS o
0
State of North Carolina
Department of Environment, Health, and Natural Resources
Wilmington Regional Office
James B. Hunt, Jr. Division of Environmental Management Jonathan B. Howes
Govemor I Water Quality Section Secretary
January 26, 1996
Certified Mail ## Z 405 591 394
Return Receipt Requested
Garland Brock
2108 Hallsville Road
Beulaville, NC 28518
. Dear Mr. Brock:
Subject: Garland Brock Farm
Facility Number: 31-578
Duplin County
On January 11, 1995 staff from the Wilmington Regional Office of the Division of Environmental
Management inspected your animal operation and the lagoon(s) serving this operation. The inspection was
in response to a complaint made to this office concerning your facility. It was observed that the primary
waste lagoon had insufficient freeboard. A second pond/lagoon located next to the primary lagoon
appeared to have at least 3 feet of freeboard at this time. No connection between this second pond/lagoon
and the waste system was found. It was also observed that the surrounding available spray fields consisted
of either dormant coastal Bermuda grass or soybeans.
USDA-NRCS guidelines require a minimum of one foot and seven inches of freeboard. This is
based on the amount of storage space needed to contain a 25-year, 24 hour design storm event without a
discharge. NRCS requirements also specify that animal waste shall be applied on actively growing crops.
And that waste nutrients shall not be applied in fall or winter for spring planted crops on soils with a high
potential for leaching. Waste nutrient loading rates on these soils should be held to a minimum and a
suitable winter cover crop planted to take up released nutrients. Waste shall not be applied more than 30
days prior to planting of the crop on bare soil.
The level of your primary waste lagoon needs to be lowered and maintained in accordance with the
MRCS guidelines and the state 2H .0200 rules governing animal waste management systems. However,
as stated above, the surrounding available fields do not appear suitable at this time for application of waste
under these guidelines. We suggest that you contact your local Soil and Water District office for any
• assistance they may be able to provide to correct the situation.
127 Cardinal Drive Extension, Wilmington, N.C. 28405-3845 * Telephone [phone] * Fax [phone]
An Equal opportunity Affirmative Action Employer

Garland Brock
January 26, 1996
Page 2.
To remain a deemed permitted facility, all corrective actions must be made within fourteen (14)
days. Failure to do so may result in the facility losing it's deemed permitted status, requiring a certified
waste management plan and certification form for the facility to be submitted prior to the December 31,
1997 deadline, and being required to obtain an individual non discharge permit for the facility.
Please be aware it is a violation of North Carolina General Statutes to discharge wastewater to the
surface waters of the State without a permit. The Division of Environmental Management has the authority
to levy a civil penalty of not more than $10,000 per day per violation.
When the required corrective actions are complete, please notify this office in writing at the address
below. I you have any questions concerning this matter, please call David Holsinger or Dave Adkins at
910-395-3900.
Sincerely,
-. 7avid R. Holsinger���
Environmental Engineer
cc: Dave Adkins Regional Water Quality Supervisor
Mike Sugg, County Soil and Water Conservation
Ronald Kennedy, County Health Department
Tom Jones, NC Division of Soil and Water Conservation
Jimmy Vinson, Brown's of Carolina
Operations Branch
31-573.1d
drb Vol. 1

T
p { f
CF ���� 4-1
I.
x"ci'•sJ �y� '�� 1�. 1 } -�.�
� 1.
}�J i
`..t lf'� `iGl .• t�J. � .- I U "
F C
4� S I•(f,�tF' '�
R
Yji .
�•Ir i5 li ri
•F! 1y
r:•�
}5 S 1 ..i''f •jj,
l 1 �I
Im
FS. 1 y 9�. TT�aT *:pti-...� . � n � t IF '•, SI4�.�Ryv'+Ufil
,a� �.�w� ' n,fS , .. el �� S,F'''� + !!y� - . I '� 5..�j.•_ r "� �� '+�''-".Rd'`'xl�l.*FK �"-F,"d• 1'�k' 't:
�,5. x. ._ y5 . 4 �� �•Ya 5.�� 4af.. kx l dt`�` i��^L,rt v'�.. E�Vs11.
1 .f •,� +''S 1 i � �, "5�. IJ. �, '� f ti -�' �'� Y K� �F � fi���,.h*I�k(�� S*
i 4. ..a .,r- . 1', :t:, �fi u �, tt ; p^ ,.�':'��� •�+ : +' .� SM �F• � �='�';,;�t 9 .
5 � `F ;,. t� �y, a ..1� r.. •I�•. "%.f � a YM' �yt �!
T.� �i .r •4f -i�,. a5..- ,A- �1(, i• � y.. 1, ° +4j f -�)r'� ,
S �s ���..� '4a y; � F�;.;. .�rFwT �`h -5.,s � ,�.�$' �+. { �' 'q�n�c`•,.�+,i{�1 ,�� ;:`i"a+.«"'''�.�''�' FLti�•5 .tip, „
s.F.����1..ry..atf. ' �a.3.•+�..r1-w'i�r.e*�o..i+.i+ws w
77
77
{��fPM9i`k'«iu }~`1r -::'.T 1_
ilyV �T

./ !IL
envitroche%
CONSULTING
CHEMISTS
NCDEHNR-DEM
127 Cardinal Dr. Ext.
Wilmington, NC 28405
0
Environmental Chemists, Inc.
MAILNG ADDRESS:
TELEPHONE:
SHIPPING ADDRESS:
P.O. Box 1037
[phone] (Office)
6602 Windmill Way
Wrightsville Beach,
[phone] (Lab)
Wilmington,
North Carolina 2M80
[phone] (Fax)
North Carolina 28405
REPORT OF ANAL Y.SIS
1/11/96 1/15/96
Date Sampled: Date o
f Re ort:
Sampled By: D E M
Report To: R i c k Shiver
p
P. 0.1: None
Reports: 2056
Fecal Coliform BY SM9222D, 18th edition (Membrane Filter)
Sample ID Lab ID# Colonies/100ml
#1 Sta 31-578 0229 280
#2 Sta Hwy. 403 0230 1160

.5
CONSULTING
CHEMISTS
Environmental Chemists, Inc.
MAn1NG ADDRESS:
TELEPHONE-
SHIPPING ADDRESS:
P.O. Box 1037
[phone] (Office)
6602 Windmill Way
Wrightsville Beach, .
(910) 3924YM (Lab)
Wilmington,
North Carolina 28490
[phone] (Fax)
North Carolina 28405
CHAIN OF CUSTODY FOR SAMPLE COLLF;CTION
M
Client: �f��%,� _ Report #
Collected By (signature & print) : p�� j��t
Sample Type Influent, Effluent, Well, Stream, Soil, Other:
Collection: For composite Indicate Date & Time for Start & Finish
Location &
identification
Sample
Type
Collection
Date Time
Bottle
ID
Lab
ID
Analysis
Requested
Transfez
Relinquished By
Date/Time
Received By
Date/Time
2
`-` Proper Preservative Used: Acid , Bas Other
Received On Ice o Chilled to 40C: Yes No
�.. �ccepted.-._.. Rej.ected_ By_: Comment'
r Comments /l
aDelivered Byvt,7
2 Date
Received By
Time