670066_INSPECTIONS_20171231

1 V
NORTH CAROLINA
Department of Environmental Qua

Type of Visit: C pliance Inspection Q Operation Review O Structure Evaluation 0 Technical Assistance
Reason for Visit: Routine 0 Complaint 0 Follow-up Referral Emergency 0 Other C0 Denied Access
Date of Visit: Arrival Time: Departure Time: County: J ,(f W Region:
Farm Name: Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact:
Onsite Representative: MAZRA sf-"Ljp
Certified Operator:
Back-up Operator:
Location of Farm:
Title:
Phone:
Integrator:
Certification Number: �9 V
Certification Number:
Latitude: Longitude:
Wean to Finish
a�
Wean to Feeder
i—
Non -La
Feeder to Finish
Farrow to Wean
Farrow to Feeder
7No
Farrow to Finish
Layers
Gilts
Boars
Poults
Other I i IMI IOther
Discharges and Stream Impacts
I. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
Dairy Cow
Dairy Calf
Dairy Heifer
Dry Cow
Non -Dairy
Beef Stocker
Beef Feeder
Beef Brood Cow
❑ Yes
No ❑ NA ❑ NE
❑ 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 ❑Z>6
❑ NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation`?
[D Yes o
❑ NA
❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters
❑ Yes WNo
❑ NA
[] NE
of the State other than from a discharge?
Page I of 3 21412015 Continued

Facility Number: - Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes je No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structure 1 Structure 2 Structure 3 Structure 4
Structure 5 Structure
6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes RfNo
❑ NA
❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a
❑ Yes jNo
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmc al threat,
notify DWR
7. Do any of the structures need maintenance or improvement?
o
❑ YesYNo
❑ 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 ADDlication
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes 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 o
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes o
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes gNo
❑ 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 WNo
❑ 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 ZNNo
❑ 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 V Rainfall Inspections
❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge?
o
❑ YesVNo
❑ NA
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
[:]Yes
❑ NA
❑ NE
Page 2 of 3
21412015 Continued

Facilit Number: - Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes ZAo ❑ 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 ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? 0 Yes XNo ❑ 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 ' N ❑ NA ❑ NE
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the ❑ Yes No ❑ NA ❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below. ❑ YesWNo ❑ 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 ]� ❑ 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 cornments.
Use drawines of facility to" better'exvinin situations.(use_addiiional_ pages as necessary).
�Ap
Reviewer/Inspector Name:
Reviewer/Inspector Signatui
Page 3 of 3
7.,A �da_, r(,JB g016,
Date:
2141201

7f
(Type of Visit: &7outine
ince Inspection U Operation Review O Structure Evaluation Q Technical Assistance j
Reason for Visit: 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access jl
Date of Visit: / Arrival Time: I__- S_l� Departure Time: County: Region:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact: Title: /
Onsite Representative: ( �r L( _54 r_ 0(4 ct
Certified Operator:
Bach -up Operator:
Location of Farm:
Latitude:
Owner Email:
Phone:
Phone:
Integrator: 7
Certification Number: t 7 J
Certification Number:
Longitude:
Design Current
Design
C*urrent
Design Current
Swine Capacity Pop.
Wet Poultry
Capacity
Pop.
Cattle Capacity : .Pop.
Wean to Finish
Layer
Dai Cow.
Wean to Feeder
Non -Layer
Dai Calf
Feeder to Finish
�rj
Dair F{eifer
Farrow to Wean
Design
C**urrent
D Cow
Farrow to Feeder
I) , P■oultr,
Ca acit
P.o ,
Non-Dai
-
Farrow to Finish
Layers
Non -Layers
Beef Stocker
Gilts
Beef Feeder
Boars
Pullets
Beef Brood Cow
"rurke s
Other
Turke Poults
Other
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 DWR) ❑ Yes ❑ No ❑ NA ❑ NE
c. What is the estimated volume that reached waters of the State (gallons)? _
d. Does the discharge bypass the waste management system? (if yes, notify DWR)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
[] Yes ❑ No ❑ NA ❑ NE
[]Yes Ef�No ❑ NA ❑ NE
❑ Yes [ No ❑ NA ❑ NE
Page 1 of 3
21412015 Continued

Facilit Number: 1p- Date of Inspection:
S
Waste Cofiection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
No
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No
❑ NA
❑ NE
Structure 1 Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
2 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
E No
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWR
7. Do any of the structures need maintenance or improvement? ❑ Yes Ef "No ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes [DNo ❑ 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 ETIN ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes EfNo ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s):
13, Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes 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
[!Noo ❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
No ❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
ErNo ❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ YesgN
o ❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yeso
❑ 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 ONo ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V Rainfall InspectirN
❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes ❑ NA ❑ NE
Page 2 of-3 21412015 Continued

Facili Number: - JDate of Inspection: r
24-Did tht facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
No ❑ NA
❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check
D Yes
to ❑ NA
❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
[] Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge?
❑ Yes
o ❑ NA
❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
❑ Yes
❑ No ❑ NA
ET B E
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes Q'No ❑ NA ❑ NE
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern? ❑ Yes No ❑ NA ❑ NE
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the ❑ Yes ❑'No ❑ NA ❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below. ❑ Yes No ❑ NA D NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes [!rNo ❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes FZ
N ❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency? ❑ Yes ❑ NA ❑ NE
Comments'.( refer to question #,)�Explarn any YES!answers and/o'.r any additionaC°r�ecommendationslor, any'ath"er:cartiirients 'a� �� '..aA�;,
Use drawings of facility to better explain situations_(use �adiiitionat age`s a"s=necessar ).
Reviewer/Inspector Name: �i `� r [ Phone: ! JQV
Reviewer/Inspector Signature: Date: q( j
Page 3 of 3 2/4 OI

Type of Visit: U Co Hance Inspection O Operation Review 0 Structure Evaluation 0 Technical Assistance ,
Reason for Visit: Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access �J
Date of Visit: Arrival Time: Departure Time:® County: QAJA6U Region:
Farm Name: Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact: Title:
Onsite Representative: (Y) A r� s4iA SA 9-6 tag
Certified Operator:
Bade -up Operator:
Location of Farm:
Latitude:
Phone:
Phone:
Integrator:
Certification Number:
Certification Number:
Longitude:
Milli Design Current
Design
C►urrent
Desigu Current
Swine Capacity Pop.
Wet Poultry
Capacity
Pop.
Cattle Capacity P.
Wean to Finish
Layer
Dai Cow
Wean to Feeder
I
INon-Layer
Dai Calf
Feeder to Finish
Dai Heifer
Farrow to Wean
Design
Current
Dry Cow
Farrow to Feeder
Dt, P,oultr.
Ca acit
P,o
Non -Dairy
Farrow to Finish
La ers
Beef Stocker
Gilts
Non -La ers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turke s
Other
Turkey Poults
Other
Other
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
❑ Yes No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
[]No
[DNA
❑ NE
[—]Yes ❑ o ❑ NA ❑ NE
❑ Yes o ❑ NA ❑ NE
❑ Yes 2No ❑ NA ❑ NE
Page 1 of 3 21412011 Continued

Facili Number: - , Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
Z 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: I fd b
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):_
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
ZNo
❑ NA
❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a
❑ Yes
[No
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes iNo ❑ 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 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?
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?
❑ Yes No ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
❑ Yes No ❑ NA ❑ NE
❑ Yes
❑ Yes
Required Records &_Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes
the appropriate box.
dNo ❑ NA ❑ NE
I No ❑ NA ❑ NE
[�No ❑ NA ❑ NE
o ❑ NA [] NE
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1 ° Rainfall Inspections ❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes o ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? [:]Yes YNo ❑ NA ❑ NE
i� 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
o ❑ NA ❑ NE
25. Is�the facility out of compliance with permit conditions related to sludge? If yes, check
❑ Yes
VN,o ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail 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
[No ❑ NA ❑ NE
Other issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
No [DNA ❑ NE
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
No ❑ NA ❑ NE
If yes, contact a regional Air Quality representative immediately.
WNo
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
❑ Yes
❑ NA ❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Yes
jNo
❑ NA ❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
Eo
o ❑ 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 facilitv to better explain situations (use additional pages as necessary).
Reviewer/inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
PhonO,09� —�Sv
Date: J L_ I 14'
2 120I1

{Type of Visit: to Cojfipliance Inspection U 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: u41�-�-LJJ Arrival Time: ®Q Departure Time: County: di j"t.) Region:
Farm Name: Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact:
Title:
Phone:
Onsite Representative: (" HA T &0 017 Integrator:
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Phone:
Certification Number: 101319
Certification Number:
Longitude:
Design Current Design C►urrent
Design
Current
Swine Capacity Pop. Wet Poultry Capacity Pop.
Cattle
Capacity
Pop.
Wean to Finish La er
Dairy Cow
Wean to Feeder
I INon-Layer
Dairy Calf
Feeder to Finish
Dairy Heifer
Farrow to Wean
Design Current
Dry Cow
Farrow to Feeder
P.
Non -Dairy
Farrow to Finish
La ers
Beef Stocker
Gilts
Non -La ers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turke s
Other
Turkey Poults
Other
Other
Discharees and Stream Impacts
1. Is any discharge observed from any part of the operation? ❑ Yes VNo ❑ 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)
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 ❑ o ❑ NA ❑ NE
❑Yes DNA ❑NE
❑ Yes No ❑ NA ❑ NE
Page 1 of 3 21412011 Continued

FaciliNumber: 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: CA&_ V, l)
Spillway?:
Designed Freeboard (in);
Observed Freeboard (in):
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?
�ye No ❑ NA ❑ NE
❑ Yes �o ❑ NA [] NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environm7_1�o
threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes 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 C No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes No
D 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
❑ 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 ��N
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 VNo
❑ 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 VNNo
❑ NA
❑ NE
the appropriate box.
❑WUP ❑Checklists ❑Design ❑Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes o ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V Rainfali InspectiWN
❑ 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 �10 ❑ 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 o ❑ NA ❑ NE
25. Is"the facility out of compliance with permit conditions related to sludge? If yes, check [:]Yes YNo ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge? ❑ Yes ��?No
o ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes 5No ❑ 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
<o
❑ NA ❑ NE
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
❑ Yes
WNo
❑ NA ❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Yes
�o
❑ NA ❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
!.d N
❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ YesVNo
❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency`?
❑ Yes
❑ 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).
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone` /U [7
Date:
/4 011

Type of Visit: UCo pliance Inspection U Operation Review .Q Structure Evaluation Q Technical Assistance
Reason for Visit: Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: a Arrival Time: Departure Time:. County: dAl$ Region:
Farm Name: Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: Title: Phone:
Onsite Representative: M fflL; -IA Si' MUD Integrator:
Certified Operator:
Certification Number: 17 3a 9
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
Design Current
aPop.
Swine Cpacity
Design C*urgent
Po
Wet ultry C►apacity Pop.
Design Current
C«attle C*apacity Pop.
Wean to Finish
Layer
DairyCow
Wean to Feeder
Non -La er
DairyCalf
Feeder to Finish
2co
ICOO
Design Current
D , P,oult . Ca aci P,o
Layers
DairyHeifer
D Cow
Non -Dairy
Beef Stocker
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Non -Layers
Beef Feeder
Soars
Pullets
Beef Brood Cow
Other NME
Other
E
HTurkeyPoults
Turke s
Other
Dischar es and Stream Impact
1. Is any discharge observed from any part of the operation? [3 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)
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 ❑ NA ❑ NE
❑ Yes �zo ❑ NA ❑ NE
Page 1 of 3 21412011 Continued

Facility Number: - (o Date of Inspection: 1Z�
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes
a. If yes, is waste level into the structural freeboard? ❑ Yes
Structure
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): '5)
[�'No ❑ NA ❑ NE
❑No ❑NA ❑NE
Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
5. Are there any immediate threats to the integrity of any of the structures observed?
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a
waste management or closure plan?
❑ Yes �No[:] ❑ NE
❑ Yes MNo ❑ NA ❑ NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environment I threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes o ❑ 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 ZNo ❑ 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
[2/No
❑ NA
❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground
❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into
Bare Soil
❑ Outside of Acceptable Crop Window [] Evidence of Wind Drift
❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
No
FVNoNA
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
o
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
[2/No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
[D,�o
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
the appropriate box.
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements
[:]Yes dNo
❑Yes 6/0
❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes 2No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ t20 Minute Inspections ❑ Monthly and 1" Rainfall Inspections ❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? [] Yes [2Zo
❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes ❑ NA ❑ NE
❑NA ❑NE
❑NA ONE
Page 2 of 3 21417011 Continued

Facili Number: 7 - Date of Ins ection:
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 ❑ YesVNo ❑ 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 ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes ��`No'
❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes 2 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 ff /No ❑ NA ❑ NE
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the ❑ Yes No ❑ NA ❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below. ❑ Yes 0 No ❑ NA ❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑Yes No ❑ NA ❑ NE
33. Did the Reviewer/inspector fail to discuss review/inspection with an on -site representative? ❑ Yes ❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency? ❑ Yes No ❑ NA ❑ NE
Comments,;(refer toquestion #):,Explain any,YES�.answers and/or any additional recam_mendations or�anyother comments_ =`
Usc-dra►vings of facility to better explairrsituatioias (use additional 'pages ias'necessary). ,�� � �,,� r •, ;;:.�� . ���:�t.2��� ���. � ,,,
Reviewer/Inspector Name:
Reviewer/inspector Signature:
Page 3 of 3
Phon 3/b 3g�
Date: i &M�✓
21417011

S
s� . aa, ak a-
fWater,Quallty
,f Sogi1janpd Water Conser-vattont } tq
type of visit (?I/Routine
Inspection O Operation Review O Structure Evaluation O Technical Assistance
1eason for Visit C7 Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: 3 g ti Arrival Time: 9q Departure Time: County: at[Lat✓ Region:
Farm Name: Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: Title: Phone No:
Onsite Representative: Mflltr (4A s'i'" VD Integrator:
Certified Operator: Operator Certification Number:
Back-up Operator: Back-up Certification Number:
Location of Farm: Latitude: = e ❑ 4 ❑ Longitude: 0 °
x s Design% CCurrent:. a ' � �'Destgn Current
Swmc Capacity Population y' Wet Poultry Capacity Pop"ulatton— Cattle {
s ;
❑ Wean to Finish
❑ Wean to Feeder
Feeder to Finish
1 Lao
1 16=0�
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
❑ Other
❑ Layer
❑ Non -La er
E
�3•" � } ib K ♦f
`
.`
s.',Dry'Ptiiltry,
,.
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
Turke Poults
FOther
❑
Daia Cow
❑
Dairy Calf
❑
Dairy Heifer
❑
Dry Cow
❑
Non -Dairy
❑
Beef Stocker
❑
Beef Feeder
❑
Beef Brood Cow
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?
Page 1 of'3
❑ Yes ZNo ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes 26No ❑ NA ❑ NE
❑ Yes ZNo ❑ 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. 1f yes, is waste level into the structural freeboard?
Structure I Structure 2 Structure 3 Structure 4
Identifier: LAC1071i
❑ Yes O No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): %g
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes [;(No ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes [;No ❑ NA ❑ NE
through a waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes Q 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 L_I No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes Z No ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes Z No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
[:]PAN ❑ FAN > 10% or 10 Ibs []Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
12. Crop type(s)
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
[irNo ❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
E No ❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
❑ Yes
O/No ❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
LD,INo [I NA
El NE
18. is there a lack of properly operating waste application equipment?
El Yes
L3 No ❑ NA
❑ NE
p - :...,... - .•: x- "i `.' S§Si s `�. �4°s 5: : x ' ',. V
Comments `(refer to.question,#) , Explain Any;Y1J5,.answers and/,or any„,recommendati,ons ar, any, other comments
Use drAwin s ity to'b'etter;ez plainesituations. (usc,additional- ppa mas n(icessarJ)
1
T
Reviewer/Inspector Name tk 1jok{tii,1-1�;�-�; Phone: ID
Reviewer/Inspector Signature: Date: 314111,
Page 2 of 3 1aia61vv Lonunueu

Facility Number: tjj— Date of Inspection 9
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 El Mans El Other
❑ Yes Z*4,0
❑ NA ❑ NE
El Yes ❑ NA ❑ NE
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes O 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? ❑ YesVNo
[INA El NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? El Yes ❑ NA ❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
lJ NNo
[]NA
ElE N
25. Did the facility fail to conduct a sludge survey as required by the permit?
El Yes
,
!d N
❑ NA
❑ NE
26. Did the facility fail to have an actively certified operator in charge?
❑ Yes
❑ NA
❑ NE
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification'?
❑ Yes
�2/0
❑ NA
❑ NE
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
.,�
[ No
❑ NA
❑ NE
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
ZNo
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
�No
[I 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
E]<o
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
dN
32. Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
❑ NA
El NE
33. Does facility require a follow-up visit by same agency?
❑ Yes
No
❑ NA
❑ NE
Additional Comments and/or .Drawings:
1
7
Page 3 of 3 12128104

Type of Visit 7ROutine
pliance Inspection O Operation Review O Structure Evaluation O Technical Assistance
ReasonforVisit O Complaint O Foilow up O Referral O Emergency 0 Other ❑ Denied Access
Date of Visit: iY 1 J
Farm Name:
Owner Name: _
Mailing Address:
Physical Address:
Facility Contact:
Arrival Time: av Departure Time: County: a1VSLAy1%J Region:
Owner Email:
Onsite Representative: A 2�13A siR—oJ0
Certified Operator:
Back-up Operator:
Location of Farm:
Phone:
Title: Phone No:
Integrator:
Operator Certification Number:
Back-up Certification Number:
Latitude: = o = 6 = Longitude: = o a
Design C►arrant
Design Current Design Current
Swine
Capacity Population
Wet Poultry Capcty Population Cattle Opacity Population
Finish
❑ La er
❑Non -Layer
❑ DairyCow
o Feeder
❑ DairyCalf
to Finish
Z.6t'�
b
❑ DairyHeifer
Dry Poultry ❑ D Cow
to Wean
Fo
to Feeder
❑ Non -Dairy
❑ Layers
❑ Beef Stocker
❑ Non -Layers ❑ Beef Feeder
❑ Pullets
El Beef Brood Cow
❑ Turkeys
to Finish
Other
❑ Turkey Poults
❑ Other I Number of Structures:
❑ Other
Discharges & Stream Impacts
dNo
1. Is any discharge observed from any part of the operation?
❑ Yes
❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
❑ Yes
❑ No
❑ NA
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
❑ Yes
❑ No
❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
❑Yes
o
❑ NA
[INE
2. Is there evidence of a past discharge from any part of the operation?
El Yes
FN
ElNA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
ElYes
No
❑ NA
❑ NE
other than from a discharge?
Page 1 of 3
12128104
Continued

i
Futility Number: — Date of inspection
Waste Collection & Treatment
4.' Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Structure 1 Structure 2 Structure 3 Structure 4
Identifier: LACIP A
❑ Yes L.idNo ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): !�
5. Are there any immediate threats to the integrity of any of the structures observed'? ❑ Yes IZNo ❑ NA ❑ NE
(ic/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes No ❑ NA ❑ NE
through a waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental t�h at, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes �No
N El ❑ 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 dNo ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes IJ No ❑ 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 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
Z o ❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
El Yes
'2o ❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
❑ Yes
17No ❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
�< ❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
No ❑ NA
❑ NE
'Comments'(refer'to question # )' Explain any'YES answers and/or any''recnmmendat ons c�r'zxny other comments].',,
'Usedrawings�of facility to better,ex'plain situations. (use'additional pages as necessary
-re- ►i i 1 5 C-6 As 150"T &, , A-r CM N NOT
fAminErJZ.6 riT N6_4-r _rxrw r
Reviewer/Ins ector Name 8 �� ` `�'��` *� s� .� '"
P r O �'�'` Phone
Reviewer/Inspector Signature: Date:
Page 2 of 3 1 12128104 ' Continued

acuity Number: 6 7 — Date of Inspection . 26
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 CAWMF readily available? If yes, check
the appropriate box. ❑ WUp ❑ Checklists ❑ Design El Maps ❑Other
❑ Yes 7No
❑ NA ❑ NE
❑ Yes ❑ NA ❑ NE
21. 7waste
ecord keeping need improvement? If yes, check the appropriate box below. LdYes ❑ No [:I NA ❑ NE
Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rain Inspection�Pvo
Weather Code
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes
❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes❑ NA ❑ NE
24. Did the facilityfail to calibrate waste application equipment as required b the pen -nit? ❑ Yes ❑ NA ❑ NE
Y P
25. Did the facility fail to conduct a sludge survey as required by the permit? ❑YesV
❑ NA ❑ NE
26. Did the facility fail to have an actively certified operator in charge? ❑ Yes WNNo ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification? ❑ Yes I No ❑ NA ❑ NE
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes 0 N ❑ NA ❑ NE
29. Did the facility fait 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 ejoNo ❑ NA ❑ NE
If yes, contact a regional Air Quality representative immediately dN
31.Did the facility fail to notify the regional office of emergency situations as required by ElYes 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 ao ❑ NA ❑ NE
33. Does facility require a follow-up visit by same agency? ❑ Yes 0 No ❑ NA ❑ NE
Additional Comments and/or Drawings: _.
Page 3 of 3 12128104

Type of Visit O Compliance Inspection O Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit Routine O Complaint O Follow up O Referral O Emergency O Other ❑ Denied Access
Date of Visit: a �► `� Arrival Time: © Departure Time: I� County: ALL-) - Region:
Farm Name: Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: ,fin S Title:
Onsite Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Phone No:
Integrator:
Operator Certification Number:
Back-up Certification Number:
Latitude: 0 c = 1 Longitude: C
�
Design Current
Design Current
11
Design Current
Swine
Capacity Pao a"ton
Wet Poultry Cap�ac ty Population
Cattle
Capacity Pnpulation
❑
Wean to Finish
❑ La er
❑Dai Cow
❑
Wean to Feeder
❑ Non -Layer
❑ Dai Calf
®
Feeder to Finish
I JA
990
❑ Dairy Heifer
❑
Farrow to Wean
Dry Poultry
❑ Dry Cow
❑
Farrow to Feeder
❑ Non -Dairy
❑
Farrow to Finish
❑ La ers
❑ Beef Stacker
❑
Gilts
❑Non -La ers
❑Beef Feeder
❑
Boars
❑ Pullets
N Beef Brood Cow
❑ Turkeys
Other
❑ Turkey Pou Its
❑ Other
❑ Other
!Number of Structures:
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
0 No
❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
❑ Yes
❑ No
❑ NA
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
❑ Yes
❑ No
❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
❑ Yes
❑ o
❑ NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
ElYes
o
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
No
❑ NA
❑ NE
other than from a discharge?
Page 1 of 3
12128104
Continued

Facility Number: — Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Structure I Structure 2 Structure 3 Structure 4
Identifier: (;(XJ
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): 34,
5. Are there any immediate threats to the integrity of any of the structures observed?
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
through a waste management or closure plan'?
❑ Yes �No ❑ NA ❑ NE
❑ Yes [:]No ❑ NA ❑ NE
Structure 5 Structure 6
❑ Yes No ❑ NA ❑ NE
❑ Yes �No ❑ NA ❑ NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental thXeat, 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 Ef N ❑ 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 ffNo ❑ NA ❑ NE
maintenance/nnprovement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes &o ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 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?
El Yes
Uo
El NA
El NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
L'J No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?❑ Yes
[�No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
6
El NA
El NE
18, Is there a lack of properly operating waste application equipment?
❑ Yes
ZN,o
❑ NA
❑ NE
-'.s '.t 4`i . .. j5,., is i. ...: . `r �r '. s.},1 .v;,, . iYi£n�ak4'w.4#`;. �,. ,.,�....
Comemepts (refer to:iquest�on::4 , Fzplaiwiny YI;S, answers and/or anyrecommendattons�or;any other comments fY F
y p
Use, drawtn s of tacilit to better,cx lain `situahons: use additional, a es as necessar :.t tt;: ' s,
g Y p P g Y. z
P I-- ------------v
Reviewer/Ins ector Name
- 0 776 - 730
o � �. Phone:
Reviewer/Inspector Signature:
Date: ,2�69
Page 2 of 3 12128104 Continued

i
Facility Number: G7 (� Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes VNo
❑NA ElNE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes ❑ NA ❑ NE
the appropirate box. ❑ WOP ❑ Checklists ❑ Design El Maps ❑ Other
21. Does record kee in need im rovement? If es, check the appropriate box below. ❑ Yes �o ❑ NA ❑ NE
P g P Y
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rain Inspections ❑ Weather Code
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes �o ❑ NA El NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment`? ❑ Yes W ❑ NA ❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes VN El NA ❑ NE
25. Did the facility fail to conduct a sludge survey as required by the permit? El Yes lCJ N ❑ NA ElNE
26. Did the facility fail to have an actively certified operator in charge? ❑ Yes WNo
O El NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification? El Yes ❑ NA ❑ NE
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes �o ElNA ElNE
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document ❑ Yes o ❑ NA ❑ NE
and report the mortality rates that were higher than normal?
30. At the time of the inspection did the facility pose an odor or air quality concern? ❑ Yes o ❑ NA ❑ NE
If yes, contact a regional Air Quality representative immediately
31. Did the facility fail to notify the regional office of emergency situations as required by ❑ Yes No ❑ NA ❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes [ZNo ❑ NA ❑ NE
33. Does facility require a follow-up visit by same agency? ❑ Yes [�No ❑ NA ❑ NE
Additional Comments and/or Drawings: ,,
Page 3 of 3 12128104

Type of Visit ergRoutine
npliance 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: S 0 Arrival Time: Departure Time: County: OAJ.("O Region:
Farm Name: Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact: ,1h Title:
/�J
Onsite Representative: I "�t�tf7V ST�
Certified Operator:
Back-up Operator:
Phone:
Phone No:
Integrator:
Operator Certification Number:
Back-up Certification Number:
Location of Farm: Latitude: = e 0 t 0 1[ Longitude: = ° 0 ` = `+
Design Current
Design
Current
Design Current
Swine Capacity Popju� lotion
Wet. Poultry Capacity
Population
Cattle Capacity Popu� lotion
❑ Wean to Finish
❑ Layer
❑Dai Cow
❑ Wean to Feeder
❑ Non -La er
❑Dai Calf
Feeder to Finish
tAfo
1036
Dairy Heifer
❑ Farrow to Wean
Dry Poultry
❑ Dry Cow
❑ Farrow to Feeder
❑ Non -Dairy
❑ Farrow to Finish
❑ La ers
❑ Beef Stacker
[� Gilts
❑ Non -La ers
El Beef Feeder
❑ Boars
El Pullets
❑ Beef Brood Cow
❑ Turkeys
Other
❑ Turkey Poults
❑ Other
❑ Other
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)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
❑ Yes
❑ No
❑ NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
[(No
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
LJ No
❑ NA
❑ NE
other than from a discharge?
Page 1 of 3
12128104
Continued

Facility Number:
Date of Inspection L1LLiLLJ
�► '��
` 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: C�Ci rrdiSr
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): Z 7
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
[2fNo ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
❑ Yes
No ❑ NA ❑ NE
through a waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or
environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement?
❑ Yes
E:fNo ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit?
❑ Yes
P 0 ❑ NA ❑ NE
(Not applicable to roofed pits, dry stacks and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require
❑ Yes
E�<o ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
L1 No ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below.
❑ Yes
P No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
12. Crop type(s)
13. Soil type(s)
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
❑ No ❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?[] Yes
0 No ❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
WIN, ElNA
ElNE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
Uo ❑ NA
❑ NE
❑/
6) Adx- c 4`1 �( d-�o ?' OTC- 6q>e0
Reviewer/Inspector Name ` >%/=�%V._f j�a2j�Kt✓ ,°k Phone: ``f (, - 39
Reviewer/Inspector Signature: Date: s— /3 '
n___ 1 _'r 17/7.P/4d rAmil'"und
­6 -1

Facility Number: — Date of Inspection 1
R it d R rd & Do um nts
eau
e eco s c e
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
rNo
❑ 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.
ElYes
�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
[(No
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
LJ No
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
� o
El NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
El Yes
VNo
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
dyes
❑ 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?
❑ Yes
o
❑ NA
❑ NE
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
ElYes
�'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
LSD
❑ 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
❑ NA
ElNE
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
o
2No
❑ NA
❑ NE
33. Does facility require a follow-up visit by same agency?
❑ Yes
❑ NA
❑ NE
Page 3 of 3 12128104

GP(D' of Water Quality
Facility Number4 0 Division of Soil and Water Conservation
-- - - O Other Agency
Type of Visit 7cmpliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: �i 4 Arrival Time: i l f (J (] J Departure Time: County: 61ALOVJ Region:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Owner Email:
Phone:
Facility Contact: Title: Phone No:
Onsite Representative: �i`"'y Integrator:
Certified Operator:
Back-up Operator:
Location of Farm:
Operator Certification Number:
Back-up Certification Number:
Latitude: = 0 0 i = Longitude: = o =' =
Design Current Destgn Current
Swine Canaeity Population Wet Poultry Capacity Population
❑ Wean to Finish
❑ Wean to Feeder E
Feeder to Finish 1
Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
. V�i�4■
❑ Other
❑ Layer
❑ Non -Layer
Dry Poultry
ElLayers
ElNon-Layers
El Pullets
ElTurkeys
Li Turkey Poults
❑ Other
ac Discharges & Stream Impts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ElStructure ❑ Application Field ElOther
a. Was the conveyance man-made?
Design�;Current
Cattle Capacity,'.:Population
El Dairy Cow
El Dairy Calf
El Dairy Heifer
El Dry Cow
ElNon-Dairy
ElBeef Stocker
ElBeef Feeder
ElBeef Brood Cow
Number of Structures-,
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
Page 1 of 3
❑ Yes /No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
El Yes
El No
El NA
El NE
❑NA
❑NE
El Yes
❑N
El Yes
No
❑ NA
❑ NE
❑ Yes & o ❑ NA ❑ NE
12128104 Continued

Facility Number: — Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Structure 1 Structure 2 Structure 3 Structure 4
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): 1/
5. Are there any immediate threats to the integrity of any of the structures observed?
(ic/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
through a waste management or closure plan?
❑ Yes 10 ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
❑ Yes [2/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 environmental th at, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes Zo
❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? El 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 WNo ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes CJ No ❑ NA ❑ NE
maintenance/improvement? �
11. Is there evidence of incorrect application? If yes, check the appropriate box below. El Yes O No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or I01bs ❑ 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 Iff El NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes [ 10 El NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ? ❑ yes ❑ NA ElNE
17. Does the facility lack adequate acreage for land application? ElYes ❑ NA ❑ NE
18. Is there a lack of properly operating waste application equipment? ❑ Yes ;No ❑ NA ❑ NE
Comments (refer to question ft Explain any YES answers and/or any recommendations or anybther'comments.
Use.drawings.of facility to better explain; situations. (use additiunal,pages as;necessary);.
Reviewer/InspectorName I Qof�}��% )Qf [ Phone:/ V10 /� � �3
Reviewer/Inspector Signature: Date: 3 1
Pane 2 of 12129104 .nntinued

`r
Facility Number: —44 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 ❑ NA ❑ NE
the appropriate 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 MN ElNA ElNE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ElYes L"! No ❑ NA ❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes �aTNa ❑ NA ❑ NE
25. Did the facility fail to conduct a sludge survey as required by the permit? El Yes VN
El NA El NE
26. Did the facility fail to have an actively certified operator in charge? El Yes ❑ 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?
❑ Yes
allo
❑ 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?
ElYes
LI No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
3 1. 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/]nspector fail to discuss review/inspection with an on -site representative?
❑ Yes
No
❑ NA
❑ NE
No
33. Does facility require a follow-up visit by same agency?
El Yes
._,
0<0
❑ NA
❑ NE
Comments and/or Drawings:
Page 3 of 3 12128104

i
EF�ity.Numberr
0 Division of
Q. Other. Ager
ter Quality:, .
and°Wieter Conservation
Type of Visit 0 YRoutine
mpliance Inspection Q Operation Review 0 Structure Evaluation O Technical AssistAce
Reason for Visit O Complaint O Follow up O Referral O Emergency O Other ❑ Denied Access
Date of Visit: Arrival Time: ® Departure Time: County: 0' Region:
Farm Name: Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Phone:
Facility Contact: Title: Phone No:
Onsite Representative: 14A RS "--up Integrator:
Certified Operator: Operator Certification Number:
Back-up Operator:
Location of Farm:
t•.
D
Swine. t Ca
❑ Wean to Finish
" ❑ Wean to Feeder
Feeder to Finish
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
Back-up Certification Number:
Latitude: = e 0 4 ❑ Longitude: = ° = ' ❑
esrgn Current
pacty Population: Wet Roultry
her
Other
i
�❑ Non -Layer
Dry Poultry
urrent. Design'. Cu r
iulation Cattle ;.Capacity Popula
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ Turkey Poults
❑ Other
❑ Dairy Cow
❑ Dairy Calf
❑ Dairy Heifer
❑ Dry Cow
❑ Non -Dairy
❑ Beef Stocker
❑ Beef Feeder
❑ Beef Brood Cow
Number of Structures
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
Page 1 of 3
❑ Yes WNo NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
El NA
❑ NE
El Yes
VNo
❑ NA
❑ NE
12128104 Continued

' Facility Number: — Date of Inspection i• b
' 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: (A 6 vz:�,J
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): Zj0
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 ElYes 2Ko ❑ NA ❑ NE
through a waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes O No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? El Yes Q No [I NA [I NI;
(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 INo ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes EfrNo, ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 Ibs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Hare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
12. Crop type(s) a u q A) S g 0
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
Q'No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
L2ryes
❑ No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
❑ Yes
Z No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
[;YNo
❑ NA
❑ NE
IS. Is there a lack of properly operating waste application equipment?
❑ Yes
ONo
❑ 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):.
r #AP-KfT Oil6tSS6�-p-
C,c ol[ -ZAMO Cdsr rkAo P_mtj S, o Fix cap mowrq o2 Swx'w zp6, wAl'Cits.
I?At,C,t 9AV6 U6+) Wa lCEO oA).
Reviewer/Inspector Name �— --- -- p Phone: 49/0
Reviewer/Inspector Signature:AAN&fz.Date: Sy
Page 2 of 3 12128104 Continued

Facility Number: — Date of Inspection
1
Required Records & Documents
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 No ❑ NA ❑ NE
the appropriate box. ❑ WUP ❑ Checklists ❑ Design ❑Maps ❑Other
21.
Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
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 0
Weather Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
E 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
❑ No
13<A
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
[;Ko
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
❑ No
ETNA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
b N
❑ 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
QNo
❑ 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
E No
Er'
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes ;2 o ❑ NA ❑ NE
33. Does facility require a follow-up visit by same agency? ❑ Yes DI o ❑ NA ❑ NE
Additional Comments and/or Drawings:
Page 3 of 3 12128104

Type of Visit fi5 Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit 0 Routine Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: jb I Arrival Time: r eparture Time: r ounty: Region: �
Farm Name: /�} (/�(% 'f�da#0 ��}�/Y1 Owner Email:
Owner Name: j r4f/7 /2 }F} %ice ;�_ Phone:
Mailing Address:
Physical Address:
Facility Contact: Title:
Onsite Representative:. _ __ __ S4�t 5
l'�DaD
Certified Operator:
Back-up Operator:
Phone No:
Integrator: Z /7} t.✓ ,�
Operator Certification Number:
Back-up Certification Number:
Location of Farm: Latitude: = e = ❑ Longitude: 0 ° ❑ 4 = "
Swine
❑ Wean to Finish
'❑ Wean to Feeder
!Weeder to Finish
Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
Other
❑ Other
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer
I; ❑ 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
❑ Daia Heifer
❑ Dry Cow
❑ Non -Dairy
❑ Beef Stocket
❑ Beef Feeder
❑ Beef Brood Cow
Number of Structures: E
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 VNo ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
0 No
❑ NA
❑ NE
❑ Yes
XVNo
❑ NA
❑ NE
12128104 Continued

Facility Number: — Date of Inspection
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? V(Yes ❑ No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes Z No ❑ NA ❑ NE
Structure 1. Structure 2 Structure 3 Structure 4 Structur 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes
No ElNA
ElNE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes
❑ No ❑ NA
V 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
Q NE
(Not applicable to roofed pits, dry stacks and/or wet stacks)
(,_f
9. Does any part of the waste management system other than the waste structures require ❑ Yes
❑ No El NA
�,,(J NE
maintenance or improvement?
/
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes
❑ No ❑ NA
Q�NE
maintenance/improvement?
/
11. Is there evidence of incorrect application? If yes, check the appropriate box below. /Yes
❑ No ❑ NA
❑ NE
❑ Excessive Ponding /ZHydraulic 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 Drill ❑ 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
VNE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
❑ No
❑ NA
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination',[]
Yes
❑ No
❑ NA
/0NE
NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
❑ No
❑ NA
NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
❑ No
❑ NA
ZNE
AV 6r"ev') /vDTz - 'w Dr
7
Reviewer/Inspector Name !. W
Phone Q
Reviewer/Inspector Signature:P Date: /
12/28/04 Continued

Facility Number: 60— Date of Inspection
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 appropirate box. ❑ WUP [] Checklists ❑ Design ❑Maps ❑ Other
❑ Yes
❑ No
❑ NA
VNE
❑ Yes
❑ No
❑ NA
Q NE
21.
Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
[]No
❑ NA
P 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
❑ 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
d] NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
❑ No
❑ NA
ONE
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
r NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
❑ No
❑ NA
NE
(�
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
❑ No
❑ NA
NE
and report the mortality rates that were higher than normal?
(((
30.
At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
'[:]No.
❑ NA
PNE
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
XNo
❑ 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
/ZNo
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
ONo
❑ NA
❑ NE
AdditionaL;Comments and/,or Drawings:.
�G! �r���� � //(� �� /9/+� /� /C, //f�1✓GGL /�zFj.�
711,�u�i✓�!L
Ice
� L.J or-J)7 r tiiU����� J� � �i� LO�iOL i✓T
�417 Wbee,G�N'��L� l!J �i✓T�GD�4�%
4 AAa,(Vf-,_e oT� Ale- A�,4 ��fe�
a� �•�?��o
12128104

Type of Visit 0 Zutine
piiance Inspection 0 Operation Review 0 Structure Evaluation O Technical Assistance
Reason for Visit 0 Complaint Q Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Date of Visit: � Arrival Time: Departure Time: County: d&)5L.ora✓ Region:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact:
Title:
Owner Email:
Phone:
Onsite Representative:. MArtSI4A _S-roL of Integrator:
Certified Operator:
Back-up Operator:
Location of Farm:
Swine
Phone No:
Operator Certification Number:
Back-up Certification Number:
Latitude: =' =' 0 Longitude: = ° =' = "
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
i
❑ La er
❑ Non -Layer
❑
Wean to Finish
❑
Wean to Feeder
x❑
Feeder to Finish
❑
Farrow to Wean
❑
Farrow to Feeder
❑
Farrow to Finish
❑
Gilts
❑
Boars
Other
❑ Other
Dry Poultry
❑
Layers
❑
Non -Layers
❑
Pullets
❑
Turkeys
❑
Turkey Poults
❑
Other
Discharp_es & 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
❑ Dai Cow
E]_Dairy Calf
❑ Dairy Heifei
❑ Pry Cow
❑ Non -Dairy
❑ Beef Stocker
❑ Beef Feeder
❑ Beef Brood Cow
Number of Structures:
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
❑ Yes dNo Cl NA ❑ NE
❑Yes
El No
El NA
❑NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes Z ❑ NA ❑ NE
ElYes VNo ❑ NA ❑ NE
12128104 Continued

Facility Number: b'%— �(D Date of Inspection �+
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes 4o ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
St re I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: (A Coat 0
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes
PJNo ❑ 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 teat, notify DWQ
7. Do any of the structures need maintenance or improvement? El Yes
LI N ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ElYes
U 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
2 rNo ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes
/No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
[--]PAN ❑ PAN > 10% or 101bs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
12. Crop type(s) &_-R'MV VA (—r,) S"
^
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
[3 o
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
[' Yes
❑ No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination
i ❑ Yes
No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
ElNA
❑ NE
18. Is there a lack of properly operating waste application equipment?
ElYes
No
❑ NA
❑ NE
�►,� 0ek_0 -to ` n_aN %(rAk_ QL-Carz iNS To QCIJ PEePAZT
we CIC wn+•b 15-'-L1 mw Coo n�S�Gn�
Reviewer/Inspector Name " %�i�ij 'n"A'' t �:
:j Phone:{9/D�3`fS'--3`% 6 Z.Z
Reviewer/Inspector Signature: Date: 41" f o $
l z/6Q/V4 i-onnnuea

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
2No
❑ 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.
iyes
❑ 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 ElWeather
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
[ A
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
❑ No
YN
NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
o
❑ PA
❑ 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
EA/No
❑ NA
❑ NE
29,
Did the facility fail to property dispose of dead animals within 24 hours and/or document
❑ Yes
E)"'No
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30.
At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
VNo
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediateiy
31.
Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
No
El NA
ElNE
General Permit'? (ie/ discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
❑ NA
El NE
33.
Does facility require a follow-up visit by same agency?
El Yes
VNo
❑ NA
❑ NE
12128104

rz
(Type of Visit 0 Compliance Inspection O Operation Review O Lagoon Evaluation
Reason for Visit o Routine O Complaint O Follow up O Emergency Notification O Other ❑ Denied Access
Facility Number Date or visit:
,Permitted 13 CertMed © Conditiio ally Certified 13 Registered
Farm Name: ........ .�......✓.u�0.........1!?
,! a .....................
Owner Name:................ t/Zl...✓`'.(......i�
................................
Time: Eli=
Not Operational O Below Threshold
Date Last Operated or Above Threshold: .........................
County: ...Q...,La................................................
PhoneNo:.......................................................................................
MailingAddress: ..................................................................................................................... ..................................................................................... ..........................
Facility Contact: .............................................................................. Title:
Onsite Representative:
................................. Phone No: ...............................................
Integrator:...........f...........................................................
CertifiedOperator: ............................................. ..... ...... ...................................................... Operator Certification Number:..........................................
Location of Farm:
Swine ❑ Poultry ❑ Cattle ❑ Horse Latitude ' 4 46 Longitude • 4 it
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes gNo
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/rain?
d. Does discharge bypass a lagoon system? (If yes, notify DWQ)
❑ Yes ❑ No
2. Is there evidence of past discharge from any part of the operation? ❑ Yes PNo
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes ONO
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway ❑ Yes ,TNo
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: ......... . ........................................................................................................................................................................................................
Freeboard (inches):
12112103 Continued

TFWaciNumber: &— Date of Inspection
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion,
❑ Yes
�No
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or
❑ Yes
No
closure plan?
(If any of questions 4-6 was answered yes, and the situation poses an
immediate public health or environmental threat, notify DWQ)
7. Do any of the structures need maintenance/improvement?
❑ Yes
VfNo
8. Does any part of the waste management system other than waste structures require maintenance/improvement?
❑ Yes
ONO
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
❑ Yes
Vf No
elevation markings?
Waste Application
Yes
ZNo
10. Are there any buffers that need maintenance/improvement?
❑
11. Is there evidence of over application? If yes, check the appropriate box below.
❑ Yes
ENo
❑ Excessive Ponding ❑ PAN Hydraulic Overl ad ❑ Frozen Ground ❑ Copper d/or Zinc
12. Crop type 6L&Mn&d
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CA )?
❑ Yes
VfNo
14. a) Does the facility lack adequate acreage for land application?
❑ Yes
No
b) Does the facility need a wettable acre determination?
❑ Yes
❑ No
c) This facility is pended for a wettable acre determination?
❑ Yes
❑ No
15. Does the receiving crop need improvement?
❑ Yes
�fNo
16. Is there a lack of adequate waste application equipment?
❑ Yes
9No
Odor Issues
17. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below ❑ Yes ONo
liquid level of lagoon or storage pond with no agitation?
18. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes �No
19. Is there any evidence of wind drift during land application? (Le. residue on neighboring vegetation, asphalt, ❑ Yes XNo
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.
�1Commenfs(�1/\refer,Eo�' uestaon`�#):t39}�pEx/M�Iatn�an �aYES9�suswers�'and/for:aayj.recommendat,ons or.,anynother comments:�� � ��e?,E ���_;5>��b���`3���, k�(,�'(t;� :�
Use drawtr�gs�rofsfacll�t�y,��tts(@;better eacplsui°situattn>s: (use a_dditional'pageseasnecessary)': ��� ❑Field Copy ❑Final Notes i�'f;g�� � �i�
qy 9
• :'r�ni ,a9tL._i.,!:<, , F.�.:: � � f � :.,x- �.t. f �!'! �9,Tti 'g "L[�(�t. ,!'.
IJr 10oQ-r ��v�F �' /�f CrD a2 ��uY 19 To
�,D
-
PAP tj
SEF't� � /I/ T'LFCr/LTGC7F��
S P�Z �J2rJao u75 iz �rfF �j S Q�P p/7/J lar., ��Trz 5!`- F A AR C
a)e-r, SO Npiz rf-8 - Ti g w MAIWi4,
Reviewer/Inspector Name �aw r - r •r <' @�@'..',:� ��w�@"� `'.:��a=kr,., s"i„ 3 W:%�1���
Reviewer/Inspector Signature: Date: �l
12112103 Continued

Facility Number: Date of Inspection
Reguired Records & Documents
21. Fail to have Certificate of Coverage & General Permit or other Permit readily available? ❑ Yes /No
22. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.) ❑ Yes VNo
23. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes 0 No
❑ 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 .-ONo
25. Did the facility fail to have a actively certified operator in charge? ❑ Yes ONo
26.
Fail to notify regional DWQ of emergency situations as required by General Permit?
4No
(ie/ discharge, freeboard problems, over application)
❑ Yes
27.
Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes
OINo
28.
Does facility require a follow-up visit by same agency?
❑ Yes
0 No
29.
Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
)6No
NPDES Permitted Facilities
30.
Is the facility covered under a NPDES Permit? (If no, skip questions 31-35)
❑ Yes
XNo
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 i" Rain
❑ 120 Minute Inspections ❑ Annual Certification Form
Lo No violations or deficiencies were noted during this visit. You will receive no further correspondence about this visit.
'�W"• �',ti 1e3'tl •>i ,��•:: E3. 7 d' i.� '+=3 •a i i 98i>: e3 - 3� '-t» ?S i E' P i 5 1 • y i� , i�`"
i,p .'LH, #, #°p a I..a €;-¢;#€�: r#€ i o E --Nr I �• °#;t El , i;i!'i.{4& ar t- :,>? € re a f`sr'#!±i f ; t€ i Ni ;E
ddltipii8l Coriiments sI1d/or;Drawlnp� z , .. `dri r� ti Ott k,'
�" � �.�&-.. aY �5. �M .�4�..:..n..
.,a�s.s�a�;nr��„ �' ?.- t�°r �tk..?kl.:a� . id��i�.;� ��Y_L �1"u� .wa. :�t€i�,f�r;_.erL:.- .R•.� ,.(3�..r..'.
1 o-r.
t) lP W E T IA D 0 Sip W W Ul N Tc. f �5 0 '2 L W Pr l or,
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qr 10
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395-3900
12112103

Type of Visit (Compliance Inspection 0 Operation Review 0 Lagoon Evaluation
Reason for Visit Routine 0 Complaint 0 Follow up 0 Emergency Notification 0 Other ❑ Denied Access
F rO Facility Number Date of Visit: Time: I I6�
Not O erational 0 Below Threshold
Permitted E3 Certified © Conditionally Certified 0 Registered Date Last Operated or Above Threshold:
Farm Name: r O County: �5 "Z_
Owner Name: a11eQ -_ Phone No:
Mailing Address:
Facility Contact: T
Onsite Representative:
Certified Operator:
Location of Farm:
Phone No:
Integrator:
Operator Certification Number:
Swine ❑ Poultry ❑ Cattle
❑ Horse Latitude 0' 0`
0" Longitude
Design
Current Design
Current Design : Current;.
Swine Capacity
Population P ultry Ca aci
Population Cattle Capacity 0o ulation
❑ Wean to Feeder
JEI
Layer
I
Dairy
Feeder to Finish
❑ Non -Layer
❑ Non -Dairy
Farrow to Wean
❑ Other
❑ Farrow to Feeder
❑ Farrow to Finish
Total Design Capacity
❑Gilts
.
❑ Boars
Total SSLW
Number of La oohs
Subsurface Drains Present ❑ La oon Area ❑ S ra Field Area
Holding Ponds 1 Solid Traps ,
❑ No Liquid Waste Management System 4 m
Discharges &c Stream Imaacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made?
b. If discharge is observed, did it reach Water of the State? (If yes, notify DWQ)
c. If discharge is observed, what is the estimated Flow in gal/min?
d. Does discharge bypass a lagoon system? (If yes, notify DWQ)
2. Is there evidence of past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge?
Waste Collection && Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5
Identifier: n
Freeboard (inches): ZZ
05103101
❑ Yes �NO
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes �N
El Yes �No
❑ Yes XNO
Structure 6
Continued

Facility Number�a i j& Date of Inspection I f Q2J
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion,
❑ Yes
No
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
Yes
No
immediate public health or environmental threat, notify DWQ)
7. Do any of the structures need maintenance/improvement?
OKcs
❑ No
8. Does any part of the waste management system other than waste structures require maintenance/improvement?
Yes
❑ No
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings?
❑ Yes
ONo
Waste Annlication
10. Are there any buffers that need maintenance/improvement?
❑ Yes
ONo
11. Is there evidence f over application? ❑ Ex ssive Ponding ❑ PAN ❑ Hydraul' Overload
ElYes
XNo
12. Crop type
13. Do the receiving crops differ with t ose designated i the Certified Animal Waste Management Plan (CAWMP)?
❑ Yes
No
14. a) Does the facility lack adequate acreage for land application?
❑ Yes
No
b) Does the facility need a wettable acre determination?
❑ Yes
o
c) This facility is pended for a wettable acre determination?
❑ Yes
15. Does the receiving crop need improvement?
❑ Yes
fNo
No
16. Is there a lack of adequate waste application equipment?
❑ Yes
1XNo
Reauired Records & Documents
17. Fail to have Certificate of Coverage & General Permit or other Permit readily available?
❑ Yes
No
18. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.)
ElYes
o
b
19, Does record keeping need improvement? (ie/ irrigation, freeboard, waste analysis & soil sample reports)
❑ Yes
No
20. Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
No
21. Did the facility fail to have a actively certified operator in charge?
❑ Yes
[ No
22. 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
(JNo
/��(/T
24. Does facility require a follow-up visit by same agency?
❑ Yes
/o
25. Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
No
© No violations or deficiencies were noted during this visit. You will receive no further correspondence about this visit.
Comments refer to �uesdon# ) z lain an AYES -answers and/or an =recammendetians or�an 'o l er%continents t
( q ) p Y Y Y,
_ ,
Uscjdrawings.of facility to better explain situations (use additional pages asnecessaiy)' ,� Field Copv ❑ Final Notes
._
s,r7-- occl,cSs Y ori�-T n1 fjGva,J [9Z f'IS �,.
r
��vrE'r.�1 DF �,Ec� G ��oo� �y� ✓� y ��w�o D.�� ��e.��e ��
L Grp oj N 0. �7 f L DWQ ��i✓ �/1Z('rrl��}{ G DEsz�NE-o. ,g,��4
v ��E �ESE7 �a�In'IE�f I.UGGPx
Reviewer/Inspector Name ,: 4-
Reviewer/Inspector Signature: Date:
O5103101 Continued

Facility Number: — Date of Inspection
Odor Issues
26. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge atlor below
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of properly within 24 hours?
28. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt,
roads, building structure, and/or public property)
29. is the land application spray system intake not located near the liquid surface of the lagoon?
30. Were any major maintenance problems with the ventilation fan(s) noted? (i.e. broken fan belts, missing or
or broken fan blade(s), inoperable shutters, etc.)
31. Do the animals feed storage bins fail to have appropriate cover?
32. Do the flush tanks lack a submerged fill pipe or a permanent/temporary cover?
❑ Yes ❑ No
❑ Yes �VNo
o
❑ Yes /
❑ Yes .12"o
❑ Yes No
❑ Yes /f �No
El Yes ❑ No
Additional Comments and/or Drawings:
-/724/
5:�r5 40FE 7�4�� Z.Oq
s��
SazL
Loo Zfie
w
,t%Q
/•gX
49 ��0 of';70ilzwlil CC e
O5103101
e�'
tF

E %o Zei bcXe v
Facility Number
Date of Visit: S 22 4 Z Time: i `f D D
Not Operational 0 Below Threshold
O Permitted M Certified 0 Conditionally Certified E3Registered Date Last Operated or Above Threshold:
Farm Name: D 0,y ip 54 , 0 Vd F r County: Qr15 rrQ
Owner Name: :Day' el 5-4 c ".0( Phone No:
Mailing Address:
Facility Contact: Title: Phone No:
rt i C.P
Onsite Representative: M4✓'S11 c, $imttd Asb ]e y Anvwf, , Ne,/e Kq Integrator: 6G en L; r'tq 4 Re t,� Ct ed . t. (_ C.
� L :. —
Certified Operator: Operator Certification Number:
Location of Farm:
❑ Swine ❑ Poultry ❑ Cattle ❑ Horse Latitude �a �° ��� Longitude
Design Current Design Current Design Current
Swine Ca aci_V Population Poultry Caaci lation Cattle Caaci Po ulaton
❑ Wean to Feeder 10 Layer[ELDairy
❑ Feeder to Finish ❑Non -La er ❑Non-Dai
❑ Farrow to Wean
❑ Farrow to Feeder ❑ Other
❑ Farrow to Finish Total Design Capacity
❑ Gilts
❑ Boars Tota S$LVV
tea: "i
-: w• Number of Lagoons ❑ Subsurface Drains Present ❑ Lagoon Area ❑ Spray Field Area ;
1
Holding Ponds.;Solid;F,raps ❑ No Liquid Waste Management System
Et.!Fk.a.,.. 3..,,... .. ... .. _ ... ....o. ,,,. q 7
Discharges _ Stream Impacts
I. Is any discharge observed from any part of the operation? ❑ Yes ❑ No
Discharge originated at: ❑ Laaoon ❑ 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 ❑ 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 8& Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway ❑ Yes ❑ No
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: t
Freeboard (inches): 2i
05103101 Continued

Facility Number: ( — Date of Inspection S 22 7-
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion,
❑ Yes
❑ No
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or
closure plan?
❑ Yes
❑ No
(If any of questions 4-6 was answered yes, and the situation poses an
immediate public health or environmental threat, notify DWQ)
7. Do any of the structures need maintenance/improvement?
❑ Yes
❑ No
8. Does any part of the waste management system other than waste structures require maintenance/improvement?
YYes
❑ No
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings?
Yes
❑ No
Waste Application
10. Are there any buffers that need maintenance/improvement?
❑ Yes
❑ No
11. Is there evidence of over application? ❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload
❑ Yes
❑ No
12. Crop type
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)?
❑ Yes
❑ No
14. a) Does the facility lack adequate acreage for land application?
❑ Yes
❑ No
b) Does the facility need a wettable acre determination?
❑ Yes
❑ No
c) This facility is pended for a wettable acre determination?
❑ Yes
❑ No
15. Does the receiving crop need improvement?
❑ Yes
❑ No
16. Is there a lack of adequate waste application equipment?
❑ Yes
❑ No
Reuuired Records & Documents
17. Fail to have Certificate of Coverage & General Permit or other Permit readily available?
❑ Yes
❑ No
18. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.)
❑ Yes
❑ No
19. Does record keeping need improvement? (ie/ irrigation, freeboard, waste analysis & soil sample reports)
❑ Yes
❑ No
20. is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
❑ No
21. Did the facility fail to have a actively certified operator in charge?
❑ Yes
❑ No
22. Fail to notify regional DWQ of emergency situations as required by General Permit?
❑ Yes
❑ No
(ie/ discharge, freeboard problems, over application)
23. Did Reviewer/inspector fail to discuss review/inspection with on -site representative?
❑ Yes
ONo
24. Does facility require a follow-up visit by same agency?
❑ Yes
❑ No
25. Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
❑ No
No violations or deficiencies were noted during this visit. You will receive no further correspondence about this visit.
I�h 9��.'� a�.Ytiyy A'��'W fFf j�Te;FM1.+.p,t nIWFYi#w i"^.,
Comments.(refer to.questiofi #) �Explalwany Yl±S answers,and/6va�nyfrecommeiidiittons or,;any;,other comments
Use drawings of facility to better explain situations' (use additional pages as necessary)'.
-„ «"«, �w,�.r,- ❑ Field Copy ❑ Final Notes
.-..,-..M__ �...,. ,�.w-.... ,.. .,S. k
84q. tvy-,• 'arena'ce Hers+ng ��r�ol;-�q-�%�A1rvg�'Gi� U6 called Me o0 5117I07-
dtrjoc✓^-�� ml. i►-,S�eG�;at� a� -�1=,:1-�a��•, qnd said 440 ��' h-to!
tie -1�°+�-t-#
level y vs ,.� a let Ser" level ok7 -�j►e 145oo>� and Gon�ei14evl e
)Of Ac
� eig Oc '�ke bi�ooh j'►'lar*Irt¢r 3W^J ahe 11gt-r lev 71,a7l
)ot„IeSi fd;n } do ~f h2 4olq v ' -4�e 1a9oOh-}1•,ere.17 Nf r. %]er✓ "v+�t GCvt-�e►lGred
- Aq4 4,e lagaa�-► kIad 20-: �rtc�ef 0/' freeloo l-) 0" s/l'710-...1 6,PP4 cd)
H,
Reviewer/Inspector Name '"
Reviewer/Inspector Signature: Date: 22 6 Z
O5103101 Continued

Facility Number: l07 - 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
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of properly within 24 hours?
28. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt,
roads, building structure, and/or public property)
29. Is the land application spray system intake not located near the liquid surface of the lagoon?
30. Were any major maintenance problems with the ventilation fan(s) noted? (i.e. broken fan belts, missing or
or broken fan bladc(s), inoperable shutters, etc,)
31. Do the animals feed storage bins fail to have appropriate cover?
32. Do the flush tanks lack a submerged fill pipe or a permanent/temporary cover?
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
Additional Comments and/or Drawings:
-laljowvlo Jo ver'T-f y /:fir.
f i i►1g5 • I�J� -lark Sever',/) el eve �' k—s arootnd �e- lay oOy,
41-,e1e r8ad,Intl s '4 a,p�egfS -� 4Lte l a9oo►7 his ZI ;�CI,eS a
4e nio, der ;s ,ead;y19
.Fromm �Ojp P7 r,.grAav
1
1 doe. A��JeDir �r -ro� Q� YYIa✓,�tW iI Se� �1�aW} 3 grtdl
o-kiP AAV �vp ,F 4he A,, ,
41s,-! lye 54a"-3 '"Of <40r PUrtip level) affemr 40 )w/ be mot✓ 42i
rre feriI 6h 47e 1490O11 ►"O"kEr-. -j)IC l ajoetl O�C3i �j+-t info✓m�t�r'�►-,
Wh,'��, i5 oc�a�l�r61e is o[a�ed, 19%B q�ld � same �F 41'e
l�,n�K�9e ;s vie vn,4er
L/4 4
by;14 1,tPotn ales; fry '?Ceds 10 lerener►�IeGt
4Zte m;n;mv,, qi MAx;mvM O)ot✓able
q 1Aje,-n? yxvge m-wke+- needs 44 6e Gert4rve,4ed
�qk,-
mid ,V)JI-A1)ad Wk;di j?qs q1 e 4°r ot<' 4e n.I,R,iker 4aivoe4-WI)
t ct.ve.S3 o,"4 an -}l,p 4of of 4)7e -C e
and W�++'��, G1ea�ly >�n✓fir ��e " " ,r"
0
)e ve4r. l 1-'Co 1 e M"q"' ev sh dot 1d
he �' AvylA+ k)',1�5 ihCrer'1E 7UO( Iq 14z: S.< ' eVeN y .Ti l' iy7cAef �e g116t,1
-rD r' . ea s ; e ✓• -AWe na rd �e� e ,r�z�1,`� q� i ac, S , � -TL, e ; 4 �"�,. s i h
-41r� need -4e be le4ed WO));n 60 XO ys ��, ZZ'/ZoOZr,
o
gls) 41.-e as ba,t ;14 /Ar" 6(el)'9 h 4V6t--t - � zJiO� �'!r✓e� �e be y,9e1v,-(ed w A1,
-'tie rme n A),7G( be qva�l-ible -(,o.- PnsrO:o'i .
05103101 t y
)e?ve1 rJeedS 40 be v.-tavitiyo( p.-plve,ri� sn qt6441"ICe
�„�r }�► �L,� laws �e�a; ;eel awl;tea? wGs-1e. mah 4pe'nleh4
v✓�de r Wh; C t, 41,e

Type of Visit .(Ef Compliance Inspection 0 Operation Review 0 Lagoon Evaluation
Reason for Visit 0 Routine 0 Complaint 0 Follow up 0 Emergency Notification Other ❑ Denied Access
Facility Number
Date of Visit: S P
02 Time: Z Z D
Not O ,rational Below Threshold
U Permitted U Certified [3Conditionally Certified [3Registered Date Last Operated or Above Threshold:
Farm Name: a„ v i d e County: O n-51 o W
Owner Name: Ay .01 S� / AV� Phone No:
Mailing Address:
Facility Contact: J Title:
OnsiteRepresentative: MA/Sks 54ro"t�[
Certified Operator:
Location of Farm:
Phone No:
Integrator:'ca r o r' �'•-+ g ]�o_W�i✓td +' G
Operator Certification Number:
❑ Swine ❑ Poultry ❑ Cattle ❑ Horse Latitude ' 6 « Longitude 0' 06 0 K
Design
Current Design Current
Design Current
Swine Capacity
Population Poultry Ca aci Po elation Cattle
Ca aci Po' ulation
❑ Wean to Feeder
1
10 Layer
I
I
'
❑ Dairy
❑ Feeder to Finish
IEJ Non -Layer
I
I
❑ Non -Dairy
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Other
❑ Farrow to Finish
Total Design Capacity
❑ Gilts
❑ Boars
Total.$8LW
Hu 'P :tuber of t,wpgoons
l ❑Subsurface Drains Present ❑ La oon Area
❑ Spray Field Area .,
x4 $
Holdm Pond"s PS611d Traps p
�
❑ No Li uid Waste Mana ement S stem
A , r
;.
Discharges & Stream Impacts
1. 1s any discharge observed from any part of the operation?
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made?
b. If discharge is observed, did it reach Water of the State? (If yes, notify DWQ)
c. If discharge is observed, what is the estimated flow in gal/min?
d. Does discharge bypass a lagoon system? (If yes, notify DWQ)
2. Is there evidence of past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge?
Waste Collection & Treatment
4. Is storage capacity (Freeboard plus storm storage) less than adequate? ❑ Spillway
Structure I Structure 2 Structure 3 Structure 4 Structure 5
Identifier: i
Freeboard (inches): _
05103101
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes
❑ No
❑ Yes
❑ No
Yes
❑ No
Yes ❑ No
Structure 6
Continued

i
Facility Number: e, ? — 4 1, 1 Date of Inspection S 1 D Z
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)
7. Do any of the structures need maintenance/improvement?
8. Does any part of the waste management system other than waste structures require maintenance/improvement?
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings?
Waste Application
10. Are there any buffers that need maintenance/improvement?
11. Is there evidence of over application? ❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload
12. Crop type
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes [:]No
❑ Yes (:1 No
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)? ❑ Yes ❑ No
14, a) Does the facility lack adequate acreage for land application? ❑ Yes ❑ No
b) Does the facility need a wettable acre determination? ❑ Yes ❑ No
c) This facility is pended for a wettable acre determination? Xyes
❑lYes ❑ No
15. Does the receiving crop need improvement? ❑ No
16. Is there a lack of adequate waste application equipment? ❑ Yes ❑ No
Reguired
Records Documents
17.
Fail to have Certificate of Coverage & General Permit or other Permit readily available?
❑ Yes
❑ No
19.
Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.)
❑ Yes
❑ No
19.
Does record keeping need improvement? (ie/ irrigation, freeboard, waste analysis & soil sample reports)
XYes
❑ No
20.
Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
❑ No
21.
Did the facility fail to have a actively certified operator in charge?
❑ Yes
❑ No
22.
Fail to notify regional DWQ of emergency situations as required by General Permit?
❑ No
(ie/ discharge, freeboard problems, over application)
-0Yes
23.
Did Reviewer/inspector fail to discuss review/inspection with on -site representative?
❑ Yes
ZrNo
24.
Does facility require a follow-up visit by same agency?
❑ Yes
❑ No
25.
Were any additional problems noted which cause noncompliance of the Certified AWMP?
OYes
❑ No
0 No violations or deficiencies were noted during this visit. You will receive no further correspondence about this visit.
{dk�ad-w«s. 4 ... . •:.�t(i-•Y. $'iPyfY%: FY V� :*
,CommentsT(�efer�topquestion #) Explairipariy,YES,aoswers end/orb"a:I,.nytrecommendatione&t,k nyiotlier com;s�,,:,ments -_ ,
iTse drawls is of`faeili ,ta bet e� ez ain°situations > use additional° 'e es asinecessar) `'§- ty P{ g Y ❑FieldCopy ❑ Fina�Notes
Tk..war 'g,
s pefAer-1eo( c4;o%, a.F-1er rtskee( r►'l•s, S-�.or.�d 41le
�r�beHfd� level by 4elelO1nane nykd 5k-e hold nee r'4 t.vq Qi%a1/e eke 40p
-peg)
7Li e revel ;s i)t v�6fa><�`o�• (� 1 ? o'v, tke5 pf' >`reebo'jId
File 1Q�de�. level jeeots 4p 6e jewe,-e rl ;nod e-e►,-iflla•jce Af
el ed;�.0(45lY qr P.- 5�'ble W11 1e OCP'%A11"Aj 1 ao� f ;ca to d 'q
ReviewerlInspector Name
Reviewer/Inspector Signature: Date: Jc t�J
05103101
Continued

Facility Number: 67 -66 Date of Inspection S i 02
Oder Issues
26, Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of properly within 24 hours?
28. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt,
roads, building structure, and/or public property)
29. Is the land application spray system intake not located near the liquid surface of the lagoon?
30. Were any major maintenance problems with the ventilation fan(s) noted? (i.e. broken fan belts, missing or
or broken fan blade(s), inoperable shutters, etc.)
31. Do the animals feed storage bins fail to have appropriate cover?
32. Do the flush tanks lack a submerged fill pipe or a permanent/temporary cover?
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
Additional Comments and/or Drawings: a
944. Can�r'+��aG�� GenD�;�io�.! a�G� fel�vi/e�+�teG'I�S Of -/he F'rtiwt�s
�Brv+�; -� cs � d Gc✓'% iF►'� �n,'�-w I 1-11�s�e /�?��� e�l� �� ��q�.
P,` cf,,rGs were +Akevt, 5
ts, The-e �,t1° �'s 4o be a good base aF b,-emvdq ;,- eke r t&,145,
tv� weed co pe►'ok% advpeetrs heA✓7 • Need 40
week Gh d gel et well s1qnd aF beormud a on
41,e e► 4;re
P nee? ca � l ; avl � lagoon level yta 4 >re1oa,`4c ° of
lle9 v 'le 4 b 7� 41, e peer . ► )'. /YP:v , s -� Gov, a'i -1 at; to 46rd 7 kR 7 -> A C�
4c'6�, h� .s�,e wAs �o relpal-4 W la.goah level -vrJ svC�, AA,�
4?,ere Lva S /2 0/ -74-,ee 6ojr'd ,
F�eebo4rad eeea�-ofs ire no4` 6,e;,\: �e14 wee,07, AJce4 4o
1<cey -'f e-eb�[or d r1ecoeds dst a week) 6ar►s ,
ZS . S Ci y V< (Ci VV rs"Te L11A 3 0,7 . e .-✓[ ii I xe ►'� TQ ��" ✓ An:,),
(Ar,S 1 C dr';,r4; ;rt�o `�Lvoads ofve ac, w-,d Gored rl;e�,s
slie Od -na4 O j vr. Also) 4Ae 4ratve.1-►-L 7 L) G r J
WCO V)n4 f vlled o c44 AS Aes,9ried 4a te pvllzd au} for q1t; s
o. pf I � ca-� ; o� � weed 4o be xV,-e - a �vll 6u � g vP1 C q e n d
O5103101

O(Division'o Water Quality
„ !
0 Division of Soil,and��Water Conservation
! - - i . I 3•, ', I: E , , ..0, Other Agency
Type of Visit 34 Compliance Inspection O Operation Review O Lagoon Evaluation
Reason for Visit Routine O Complaint O Follow up O Emergency Notification O Other ❑ Denied Access
Dale of Visit: G Tirne: 0 U Printed on: 7/21/2000
Facility Number
0 "Not Operational 0 Below Threshold
Permitted ❑ Certified 0 Conditionally Certified © Registered Date Last Operated or Above Threshold:
.........................
Farm Name: ��s/ l ..G.. .... County:... .. GL.....................................................
............................................ .................................................................. ......
OwnerName: ................................................... ........................................................................ Phone No:.......................................................................................
FacilityContact:............................................................ ..................'ritle:................................................................ Phone No:...................................................
Mailing Address: ...............(... ...
...........-............................................................................................................................................
Onsite Representative: .... .v1..h-.2.......................................................................... Integrator: ....'<`1.................................................
Certified Operator: . Operator Certification Number:.,
Location 'of Farm:
❑ Swine ❑ Poultry ❑ Cattle ❑ Horse Latitude �• �� ��� Longitude �• ��i�
Design Current
Ine
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Design Current :', Desiga`Current
Poultry Capacity Population Cattle ,Ca eici IPo `ulatiom
❑ Layer ❑ Dairy
❑ Non -Layer I Non -Dairy
❑ Other
Total Design Capacity
Total ►r1SM
rE' Numberof Lagoons ❑ Subsurface Drains Present ❑ Lagi n Area 10 Spray Field Area
•Holtlitng Ponds./Solid Traps ' ❑ No Liquid Waste Management System i
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made?
b. If discharge is observed, did it reach Water of the State? (If yes, notify DWQ)
c. If discharge is observed. what is the estimated flow in gal/min?
d. Does discharge bypass a lagoon system? (if yes, notify DWQ)
2. Is there evidence of past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge?
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5
❑ Yes,
R1 No
❑ Yes
❑ No
❑ Yes
❑ No
❑ Yes ❑ No
❑ Yes ls�No
❑ Yes rvrWY No
❑ Yes �rNo
Structure 6
Identifier: ...............................................................................................................................................
Freeboard (inches): g-
5/00
Continued on back

FaciltSy Number: — Date of Inspection � Printed on: 7/21/2000
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)
7. Do any of the structures need maintenance/improvement?
8. Does any part of the waste management system other than waste structures require maintenance/improvement?
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings?
Waste Application
10. Are there any buffers that need maintenance/improvement?
11. Is there evidence of over application? Q Excessive Ponding ❑ PAN ❑ Hydraulic Overload
12. Crop type , 5-1, .A ci __ ,
r y
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?
Rewired Records & Docti ments
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 Reviewer/Inspector fail to discuss review/inspection with on -site representative?
24. Does facility require a follow-up visit by same agency?
25. Were any additional problems noted which cause noncompliance of the Certified AWMP?
N,0.yijAati0As'0r &r1d nde*ere nQte�1 ��triti� th#s;v sit! Yop ;wild reeRio; #'uTth¢r ;
Torres oricieirce:aboU this visit. ..... .............. .
❑ Yes Arlo
❑ Yes �No
❑ Yes C9 No
❑ Yes Callo
❑ Yes C5 No
❑ Yes PTNo
❑ Yes t No
❑ Yes VNo
❑ Yes E "No
❑ Yes NrNo
❑ Yes CgNo
Yes ❑ No
❑ Yes 4No
❑ Yes Z No
❑ Yes 14 No
❑ Yes XNo
❑ Yes ,tT No
❑ Yes r—
❑ Yes No
❑ Yes (� No
❑ Yes No
❑ Yes 'OrNo
Comments (refer to question #): Explain any YES answers and/or any recommendations or any other comments
[Ise drawings of facility to better explain situations: (use additional pages as necessary).
�jQ_ r GSs`Ibist I'� �� �' �, c "-s'-\-
lS) �eco+�-.��• s��-o;t �L,� c�;�s�� �.-,� �\e., � �� �+ ys �F �c� �se�.s,
Vp
Reviewer/Inspector Name
Reviewer/Inspector Signature:
p
Date: -�— d — U i 5/O0

Fad ity Number: — Date of inspection 8 Q Printed on: 10/26/2000
Odor Issues
26. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below ❑ Yes No
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of property within 24 hours? ❑ Yes W"I'-JNo
28. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt, ❑ Yes qNo
roads, building structure, and/or public property)
29. Is the land application spray system intake not located near the liquid surface of the lagoon? ❑ Yes � No
30. Were any major maintenance problems with the ventilation fan(s) noted? (i.e. broken fan belts, missing or
or broken fan blade(s), inoperable shutters, etc.) ❑ Yes ( No
31. Do the animals feed storage bins fail to have appropriate cover? ❑ Yes No
32. Do the flush tanks lack a submerged fill pipe or a permanent/temporary cover? ❑ Yes] No
Additional,Cornments an or' ravings:
("'A
l �
5100

* ` Division of Water Quality
Division of Soil and Water Conservation
0 Other.Agency
Type of Visit 1K
ompliance Inspection Q Operation Review 0 Lagoon Evaluation
Reason for Visit 4 Routine O Complaint O Follow up O Emergency Notification O Other ❑ Denied Access
Facility Number Date of Visit: -CQ fiine: © Printed on: 7/21/2000
Q Not O erationat Q Below Threshold
0 Permitted io Certified 0 Conditionally Certified [] Registered Date Last Operated or 'lbove Threshold: .........................
FarmName: ��v +-.� ......................... County: ... `^!................................. .......................
OwnerName: ......... Phone No: .......................................................................................
Facility Contact: ...............................................................................title:........................................................ Phone No:
...........................................................
MailingAddress: ..................................................................................................................... ..........................................
.......................
Onsite Representative: . ^'....................................... ............... I...................... Integrator:..................:......................................................
Certified Operator: ................................................... ............................................. . .............. Operator Certification Number:..........................................
Location of Farm:
..
❑ Swine ❑ Poultry ❑ Cattle ❑ Horse Latitude • 4 44 Longitude 0 4 64
Design Current Design Current Design Current
Swine Capacity Population Poultry Capacity Population Cattle Capacity Population
❑ Wean to Feeder ❑ Layer ❑ Dairy
Feeder to Finish ❑ Non -Layer ::::::]I JE] Non -Dairy
❑ Farrow to Wean
❑ Farrow to Feeder Other
❑ Farrow to Finish Total Design Capacity
❑ Gilts
❑ Boars Total SSLW
Number of Lagoons i i J❑ Subsurface Drains Present E] Lagw,n Area J❑ Spray Field Area I
Holding Ponds 1 Solid Traps IC I No Liquid Waste Management System
Discharges & Stream Impacts
1. Is any discharge observed Isom any part of the operation?
Discharge originated at: []Lagoon ❑ Spray Field ❑ Other
a. If discharge is ohscrvcd, was the conveyance man-made''
h. If discharge is observed. did it reach Water of the State? (If yes, notify DWQ)
c, Il' discharge is observed, what is the estimated flow in gallrrtin?
d. Does discharge bypass a lagoon system? (If yes, notify DWQ)
2. is there evidence of past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge?
Waste Collection & Treatment
4. is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway
Structure I Structure 2 Structure 3 Structrre 4 Structure 5
Identifier:.....................................................................................................................................
Freeboard (inches):
5100
❑ Yes ONO
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes k No
❑ Yes )<No
Yes ❑ No
/1-111
Structure 6
Continued on back

Faci Q y Number: Z ]late of Inspection Printed on: 7/21/2000
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, ❑ Yes XNo
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or
closure plan? ❑ Yes XNo
(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
10 No
8. Does any part of the waste management system other than waste structures require maintenance/improvement?
❑ Yes
XNo
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings?
❑ Yes
>1"No
Waste Application
10, Are there any buffers that need maintenance/improvement'?
❑ Yes
b "No
11. Is there evidenc over application'? ❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload
[I Yes
�No
12. Crop type o
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)?
❑ Yes
KNo
14. a) Does the facility lack adequate acreage for land application?
❑ Yes
RfNo
b) Does the facility need a wettable acre determination?
❑ Yes
❑ No
c) This facility is pended for a wettable acre determination?
❑ Yes
❑ No
15. Does the receiving crop need improvement'?
❑ Yes
%No
16. Is there a lack of adequate waste application equipment?
❑ Yes
No
RC uired Records & DOCLimCntS
17. Fail to have Certificate of Coverage & General Permit readily available?
❑ Yes
No
18. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ W11P, checklists, design, maps, etc.)
❑ Yes
�ZNO
19. Does record keeping need improvement? (ie/ irrigation, freeboard, waste analysis & soil sample reports)
❑ Yes
XNo
20. Is facility not in compliance with any applicable setback criteria in effect at the time of design'?
❑ Yes
�ZNo
21, Did the facility fail to have a actively certified operator in charge'?
Cl Yes
ONo
22. Fail to notify regional DWQ of emergency situations as required by General Permit'?
(ie/ discharge, freeboard problems, over application)
❑ Yes
P'No
23. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative'?
❑ Yes
C5No
24. Does facility require a follow-up visit by same agency?
❑ Yes
[7No
25. Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
ONo
iS'04114ti0tis or- &fleje;nt&9 •were noted d(Wing this'visit' • Y:oit 'Will. eeeiye 00; furthor ; ;
corresoondence. a crut this .visit. .
Comments (refer to question #): Explain any YES answers and/or any recommendations or any other comments.
Use drawings of facility to better explain situations. (use additional pages as necessary):
NUJ. ice• li q , �C re ,�� �� t s �Q e- U-e .
GLb 6 �� �� �� TQ'..' j ►-t�`�y &V4A -� C �-tiS�' C;J
Yam/ d L­
4 a r�.tt, c� (:T X oo G
Reviewer/Inspector Name <P— 141 G �� 3
Reviewer/Inspector Signature: Date: —ag-00 5100

Fa ility Number: —6 Date of Inspection Printed on: 7/21/2000
Odor Issues
26. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge Wor hPlow KYes ❑ No
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes fff No
28. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt, ❑ Yes No
roads, building structure, and/or public property)
29. Is the land application spray system intake not located near the liquid surface of the lagoon? ❑ Yes 4-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 ;tj No
32. Do the flush tanks lack a submerged fill pipe or a permanent/temporary cover? ❑ Yes ANo
Additional Comments and/orDrawings: �4M
JGL-e�—JV-7[[
3
(9�
J
5/00

(] Permitted 10 Certified © Conditionally Certified y[�,�,Registered Not Operational
I Date Last Operated:
Farm Name: c_1� y ..... ... �a` 1 County .....G.l..nf.L......................................................
.......... ..........I�A..... S1 r '. V
' � rD 1l d
OwnerName:G V, �.�.................................................................................... Phone No:.......................................................................................
Facility Contact: .................................. Title:................................................................ Phone No:
Mailing Address:
Onsite Representative:........` ArS h,A.......4.rP.ti.�r.'...................................... integrator: .�.��I..t�....................:.............................
Certified Operator: ................................................... ............................................................. Operator Certification Number:..........................................
Location of Farm:
i
...I ......... ...................... .......................................................... .........I.... 1
Latitude �° �'� Longitude • �' �"
:. Design
Current '' -,.." Design Current
Design Current
Swine p Capacity
Po ulation 1?loultry I',;Capacity-Population, Cattle ; „ Capacity Pop"ulation
- ❑ Wean to Feeder
" ❑ Layer I I ❑ Dairy
® Feeder to Finish 12,00
1 Z 0 ❑ Non -Layer I Non -Dairy
" ❑ Farrow to Wean
;.,, . ,'iP ,... ;t.,. 3...�,di, ;.,., . yi E
�..
❑ Farrow to Feeder
❑Other
[]Farrow to Finish
I'll
Total Design Capacity_
❑ Gilts,
Boars
SSL Total � W
r ? of Lagoons
JEI ent Subsurface Drains Pres
❑ Lagoon Area
JE1 ea Spray Field Ar
❑ No Liquid Waste Management System
,Number
Holding Ponds / Solid Traps
Discharges & Stream Impacts
I. Is any discharge observed from any part of the operation? ❑ Yes No
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made'? ❑ Yes No
b. If discharge is observed, did it reach Water of the State? (If yes, notily DWQ) ❑ Yes No
c. If discharge is observed, what is the estimated flow in gal/min'? h A
d. Does discharge bypass a lagoon system? (II'yes, notify DWQ) ❑ Ye4 a No
2. Is there evidence of past discharge from any part of the operation? ❑ Yes C9 No
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes IgNo
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway ❑ Yes 25 No
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier.
Freeboard(inches):........2.z...................................................................................................................... ................: .......................... I.....................
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, ❑ Yes X No
seepage, etc.)
3/23/99 Continued on back

Facility Number: Date of Inspection
Are 14cre structures on -site which are not properly addressed and/or managed through a waste management or
closure plan? ❑ Yes No
(If any of questions 4-6 was answered yes, and the situation poses an
immediate public health or environmental threat, notify DWQ)
7. Do any of the structures need maintenance/improvement? Yes ❑ No
8. Does any part of the waste management system other than waste structures require maintenance/improvement? ❑ Yes ;K No
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings? ❑ Yes 'N No
Waste _Application
10. Are there any buffers that need maintenance/improvement? ❑ Yes No
11. Is there evidence of over application? ❑ Excessive Ponding ❑ PAN ❑ Yes ffi No
12. Crop type Q S
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)? ❑ Yes '$j No
14• a) Does the facility lack adequate acreage for land application? ❑ Yes T$No
b) Does the facility need a wettable acre determination? ❑ Yes 21I`No
c) This facility is pended for a wettable acre determination? ❑ Yes ONo
15. Does the receiving crop need improvement? j5Yes ❑ No
16.
Is there a lack of adequate waste application equipment?
❑ Yes 0No
Reuuired Records & Documents
17.
Fail to have Certificate of Coverage & General Permit readily available?
Yes
❑ No
18.
Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.)
❑ Yes
ONo
19.
Does record keeping need improvement? (ie/ irrigation, freeboard, waste analysis & soil sample reports)
9Yes
❑ No
20.
Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
ONo
21.
Did the facility fail to have a actively certified operator in charge?
❑ Yes
ONo
22.
Fail to notify regional DWQ of emergency situations as required by General Permit?
❑ Yes
A No
(ic/ discharge, freeboard problems, over application)
23.
Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes
ONo
24.
Does facility require a follow-up visit by same agency?
❑ Yes
I-4No
25.
Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
XNo
E; 1(violatiQiis;or dt'ficiencies ire 00 ed iltrr:ing �his;visit: You wi#i i•eceiye Rio; fu>�-ti1 r
corres' oric�e�tce: a�atit: this visit: • • • • • • • ' ' • • • • • . • •
Comments `(refer fo;questton #) Explain'
any,YES�answers�andlor any' recommendations o`rianytother cami�ittents ?, r P 1
Useidrawtngs of facility W.better explain situations (use additionaf' .ages as necessary) , ti
P C �.. . _ i • <: r,.1.t:.t� € .• tri.::" vt, �2 E E 3 �z�. •,., �, -> f,. _.... .. cw 3 �� �'{. s�3'3.1 �•C �.... �.. ..t , _. . - r E� ,E F - E E ¢...?u F.f�.. 3 �aa r 'f Ls3 u, t
7. Work �o �5-�ab��',f� 5rwfs eh t Are 4teev Oh 141,0,0n LJQ��s.
IS, s-rv► i I - j9' tr►-,vd A (;e1,4 P7eek iomf rotre►Mc)14,' 14-1re41eQ,reae,
PA roll e r 5, f r; at 049 q rel irl s% e l'rl A�l�� y d i rrt..e Qzbord;Y7
17 co 6ilorp e- ke . I � ',eeordl. Aeek 1j;4
y
3l23/99

Facility Number: — hate of inspection
O or Jssues'
26. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below ❑ Yes )% No
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of properly within 24 hours'? ❑ Yes J9rNo
28. Is there any evidence of wind drift during land application? (i.e. residue on. neighboring vegetation, asphalt, ❑ Yes ,WNo
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 ONo
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 9No
31, Do the animals feed storage bins fail to have appropriate cover? ❑ Yes 9No
32. Do the flush tanks lack a submerged fill pipe or a permanent/temporary cover? $ Yes ❑ No
Additional ommen and/or, rawines f� ,n
{7tjorrCG'� -f-�e GtG/P.Gt a T✓a+'✓1 ��. +0 /.IS AGraS oil 64s7al �rie�� 11
qnd retaloubo14e S- - 1
l7g v e. ✓''1 o ee re Ce P[� 1 e Ypk 0 V? ,rko w , P1a G I e g leaf Ig y1
-,Coy' ra t m • J
14,^ve kmf4e r cri rewl Ail Id l►'Ou e /I. cab AGtoS Ao^-v
/4a� &ile-e 4A4 A roe P.X(0.5ed s�o� i� �e r ewLoVed dr U�rl r d
woe✓ one y eA r .
3/23/99

v 4i '�.�++ NiiwY#ikalVwlw4wr''w a�f.aa awa �ii.�w��wrSY 9ratiauwMNww`�a��ii.w...wi.4 ax.r:dkwMwwYi..n.r.Sii
� y:.
Fk ��._ !II
plkk ':�y� p^x �,
U Division of Soil and Water Conservation D Other Agency#
yxt
'E
Division of Water Quality
y.
IS outine 0 Coni faint 0 Follow-up of DWQ inspection 0 Follow-up of DSWC review 0 Other
Date of Inspection G
Facility Number Time of Inspection �/S' 24 hr. (hh:mm)
13 Registered Certified Applied for Permit Permitted 0 Not O erational I Date Last Operated:
Farm Name: . .1.: fi, ..� Count � . .......................
Owner..................... -..�...................... y:.............................
Owner Name:... ,,Rol/. ...... .20✓ ................................................... Phone No: ...... 50..E ....31 2-c;.................................
Facility Contact: ....� / ! 5.. i.......5`� .4�........... Title: ...... h7��!..1.9 ......................../...... Phone No:...................................................
Mailing Address: ...... :11...Zip...... ��1.1 r xJ.. v�vr7........ ............. ........ F ! 1. ..................................... .........5"""' 1
�^ 2
Onsite Representative:.. .. ^.z..S.1r..7A....................,.. .. tJs1.................... ^ 7 yb
�iA l"�...... InteKrator:......Y�.�.v.�....................
Certified Operator:........ ......................... .. Operator Certification Number_&..��y............
Location of Farm: �"'�` S
C
C
Latitude • =' ='4 Longitude 0' =' ="
�Desxgn Current
Swine Capactty Poultry;,°
Design Currenit ` Design Current
Capacity Pnpulatxan CatEle :,CapaclEy Population
�o-
+Population
p
❑ Wean to Feeder
❑Layer
❑ Dairy
Feeder to Finish
f
❑Nan -Layer
❑ Non -Dairy
El Farrow to Wean
, .;,.
�y
❑ Farrow to Feeder
❑ Other
x#;
❑ Farrow to Finish
Total Design CapaC ty
R
❑ Gilts
❑ Boars
sr Total SSE:
Naaiber of,Lagoons /Holding Ponds 0 ❑ Subsurface Drains Present
..
ID Lagoon Area
❑Spray Feld Area
f Ax
„ x< .:
❑ No Liquid Waste Management System
_
.
General
1. Are there any buffers that need maintenance/improvement?
❑ Yes
IM No
2. Is any discharge observed from any part of the operation?
❑ Yes
El -No
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made?
❑ Yes
E3-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 gaUmin?
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
EJ No
4. Were there any adverse impacts to the waters of the State other than from a discharge?
❑ Yes
WNo
5. Does any part of the waste management system (other than lagoons/holding ponds) require
0 Yes
❑ No
maintenance/improvement?
6. Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
UNo
7. Did the facility fail to have a certified operator in responsible charge?
❑ Yes
O No
7/25/97

w F
Facility Number: --
8. Are there lagoons or storage ponds on site which need to be properly closed?
Structures {LagoonsAolding Ponds. Flush Pits
9. Is storage capacity (freeboard plus storm storage) less than adequate?
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5
Identifier:
Freeboard(ft): ........................................................................................................................................I.............
10. Is seepage observed from any of the structures?
11. 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)
15. Crop type ..........<Z.A......................................................... Y...............................................................................
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?
❑ Yes g,No
❑ Yes Z) No
Structure G
...................................
❑ Yes 9[ No
❑ Yes 9 No
�] hio.vialatiohs,6i del"icien' de's:werenoteddtiring this.visit. Aodviiffl receive ito-ftirEheri, `
. eQrrespondei>tce ab;ou� tilis:vis�t:-: ..... ... ' .
✓�.° cs-r J
(A Yes ❑ No
❑ Yes 0 No
❑ Yes ® No
................................
❑ Yes Wj No
❑ Yes MNo
❑ Yes ,® No
❑ Yes No
❑ Yes No
❑ Yes [(No
VYes ❑ No
❑ Yes ErNo
EfYes ❑ No
Yes
NFL 4D XP
71-.,e
Sv ie If /✓ 70k'9L af9"r- �A� L•�..,�
7/25/97

Farm Status: Registered ❑ Applied for Permit
❑ Certified ❑ Permitted
❑ Not Operational Date Last Operated:
Farm Name: ..l.....
ki�.........�t�.A.k...».�_�?.V� County: L/tL5�0—
Land Owner Name: G1 ..[4t1_f: ...., ....... .......................... Phone No: ......3.............. 39*w.................................
Facility Conctact:.MQ3.t(',4, X{,,,,,,....!S7j.fl.��....✓7.. Title: .`fGU�'tc(...,,,,,,,,,,,,,,_.. Phone No:.?j
Mailing Address: ... LrI.,ZL?........ fl/l rt�fl7!%TJK/i1/... ��..»......... _.......
...JL..[.C.��l�i�/��.................................... yFSS i�f'
OnsiteRepresentative: ...JKf'Ai.��1.�f� ,,,,,,,,,,,,,,,,, T�....!/J�................... Integrator:
Certified Operator: ........ /.,.....,�� ,,,,, ,,,,,,,,,,�. �7 v..._......... Operator Certification Number: ........................... »........ _...
Location of Farm:
Latitude =0=1={I
Type of Operation and Design Canacir
Other
Longitude =• =1 =11
a t'" �U Lagoon Area x Spray Field Area
General
1. Are there any buffers that need maintenance/improvement? ❑ Yes Mo
2. Is any discharge observed from any part of the operation? ❑ Yes 9-No
Discharge originated at: ❑ Lagoon ❑ Spray field ❑ Other
a. If discharge is observed, was the conveyance man-made? ❑ Yes B-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 MNo
3. Is there evidence of past discharge from any part of the operation? ❑ Yes 9-Ko
4. Were there any adverse impacts to the waters of the State other than from a discharge? ❑ Yes URNO
5. Does any part of the waste management system (other than lagoons/holding ponds) require Yes ❑ No
4/30/97 maintenance/improvement?
Continued on back

y
IFacility Number: ,iP..f... ..... bl( .. I
6. Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
BIC
7. Did the facility fail to have a certified operator in responsible charge?
❑ Yes
Rio
8. Are there lagoons or storage ponds on site which need to be properly closed?
❑ Yes
W14o
14ruetttr-e--s(jagoons nd/or Hold ia Fonds)
9. Is storage capacity (freeboard plus storm storage) less than adequate?
ER Yes
❑ No
Freeboard (ft): Structure I Structure 2 Structure 3 Structure 4 Structure 5
Structure 6
P &
............................ ............................ ............................ ............................ ............................
.... I.......................
10. Is seepage observed from any of the structures?
❑ Yes
19No
11. Is erosion, or any other threats to the integrity of any of the structures observed?
❑ Yes
DNo
12. Do any of the structures need maintenance/improvement?
B"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?
O'Yes
❑ No
Waste_ Application
14. Is there physical evidence of over application?
❑ Yes
2No
(If in excess of WMP, or runoff entering waters of the State, notify DWQ)
15. Crop type .......................................................................................................................................................................
16. Do the receiving crops differ with those designated in the Animal Waste Management Plan (AWMP)?
❑ Yes
/
MIND
17. Does the facility have a lack of adequate acreage for land application?
❑ Yes
[ -IZ
18. Does the receiving crop need improvement?
[9"Ves
❑ No
19. Is there a lack of available waste application equipment?
[(Yes
❑ No
20. Does facility require a follow-up visit by same agency?
❑ Yes
dNo
21. Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
For Certified Facilities Only
❑ Yes
E(No
22. Does the facility fail to have a copy of the Animal Waste Management Plan readily available?
❑ Yes
No
23. Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
No
24. Does record keeping need improvement?
❑ Yes
ENo
Cbm ent i (refer to `question #) Explain any YES answers' and/or anyRrecoinmendations o`r any other comments ,,,
Use.�drawin s, -f facili to better.ex -lam situations. use additional a es asf necess '
,.x r)` P F g azY) s,
.....
i ) rn)
t.ay.i3Hn�Q. 5*vas G'ir.s-e �v
A
W�FS S �+t � � G�i � •1 „� �.iJ C.. :5�'" C (I R +J '% Ip SIK�vi'o i3 �cm� ,
-rb c✓� 4.0� NDD
Reviewer/Inspector Name NO MR.
Reviewer/Inspector Signature: Date:
cc: Division of Water Quality, Water Quality Section, Facility Assessment Unit 4/30/97