310855_INSPECTIONS_20171231

NUH I H UAHULINA
Department of Environmental Qual

Type of Visit: ,-G-eompliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: J2rRoutine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: Departure Time: O County:
Farm Name: ��Z Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact:
Phone:
Title: Phone:
Onsite Representative: o R Gt
Certified Operator:
Back-up Operator:
Location of Farm: Latitude:
Integrator: Ll, f . j
Certification Number:
Certification Number:
Longitude:
Region:
Swine
Wean to Finish
Design Curren#
Capacity Pop.
Design Current
Wet Poultry Capacity Pop.
Layer
Design Current
Cattle Capacity Pop.
Dairy Cow
Wean to Feeder
HNon-Layer
Dairy Calf
Feeder to Finish
Dairy Heifer
Farrow to Wean
Design
D . P,ouit, Ca act P,o ,
I Lavers
Dry Cow
Farrow to Feeder
Farrow to Finish
Non -Dairy
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Other
F-TO—ther
keys
Turkey Poults
Other
Discharees and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWR)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWR)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
❑ Yes LT'No ❑ NA ❑ NE
❑ Yes No
❑ Yes No
[] Yes E; i�io
ElYes'* o
❑ Yes No
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑NA ❑NE
❑ NA ❑ NE
Page 1 of 3 21412015 Continued

Facili Number: - Date of Inspection:
Waste Collection'& Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes 0 No
a. If yes, is waste level into the structural freeboard? ❑ Yes 'VNo
❑ NA ❑ NE
❑ 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?
(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 P�No
❑ Yes dN0
❑ NA ❑ NE
❑ NA ❑ NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWR
7. Do any of the structures need maintenance or improvement? ❑ Yes ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes ❑ No ❑ NA ❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks) 640
9. Does any part of the waste management system other than the waste structures require ❑ Yes ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes �No ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes ❑'No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
15. Does the receiving crop and/or land application site need improvement?
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
the appropriate box.
❑ Yes
;3No
❑ NA
❑ NE
❑ Yes
_VNo
❑ NA
❑ NE
❑ Yes
NA
❑ NE
❑ Yes
rX1Vo
❑ NA
❑ NE
❑ Yes ( ZNo ❑ NA ❑ NE
❑ Yes �TNo ❑ NA ❑ NE
0 Yes JINo ❑ NA ❑ NE
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes "[20Ro
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and l" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes �N
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes PIWO
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
o ❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 21412015 Continued

Facili Number: - Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permi .
❑ Yes
4 No
❑ NA ❑ NE
2; Is the facility out of compliance with permit conditions related to sludge? If yes, check
❑ Yes
0"'No
❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge
levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge?
❑ Yes
PNo
❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
❑ Yes
7No
❑ 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?
T
24. At the time of the inspection did the facility pose an odor or air quality concern?
[:]Yes
PTNo
❑ 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
E;3"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 r7rNo
[DNA
❑ 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 o
❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes &No
❑ NA
❑ NE
Comments (refer to question ft Explain any YES answers and/or any additional recommendations or any other comments.
Use rawinsof faci tyto better ag"'fs use additional pages as necessary)- ain situation . .
`e 160IC5 job
Reviewer/Inspector Name: i� Phone: 6
Reviewer/Inspector Signature: !C Date:
Page 3 of 3 21412015

Type of Visit: _(?Tompliance 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 0 Denied Access
Date of Visit: Arrival Time: Departure Time: County: Region:
Farm Name: Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: Title: Phone:
1�
Onsite Representative: , ).Yp �1/j�(t% Integrator:
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Certification Num er:
Certification Number:
Longitude:
Design
Swine Capacity
C*urrent
Pop.
Wet Poultry
Design Current
C•apaeity Pop. Cattle
Design Current
C•.apacity Pop.
Wean to Finish
Layer
airy Cow
Wean to Feeder Q Q
Non -La er
airy Calf
Feeder to Finish
airy Heifer
Farrow to Wean
Design Current D Cow
Ca aci Plo Non-DaiEX
Farrow to Feeder
lt .
Farrow to FinishJ
Stocker
Gilts
7Layers
ers
BeefFeeder
Boars
Beef Brooder
Other
Puults
Other
VBeef
Discharees and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWR)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWR)
2. is there evidence of a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
❑ Yes ZZ o ❑ NA ❑ NE
❑ Yes ,EJ No
❑ Yes Ef No
❑ Yes WJ No
❑ Yes el No
❑ Yes ZNo
❑ NA ❑ NE
❑NA ONE
❑ NA ❑ NE
❑ NA ❑ NE
0 NA ❑ NE
Page I of 3 21412015 Continued

Facili Number: Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes Pr4o
a. If yes, is waste level into the structural freeboard? ❑ Yes [;�No
❑NA ONE
❑NA ❑NE
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: 1
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes No ❑ NA ❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a ❑ Yes F
No ❑ NA ❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWR
7. Do any of the structures need maintenance or improvement? [:]Yes [;; No ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes No ❑ NA ❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes PrNo ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes A No ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes ;XNo ❑ 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 A No ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes �I No ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes 0 No ❑ NA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
❑ Yes FYNo ❑ NA ❑ NE
❑ Yes Z No ❑ NA ❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes PNo ❑ 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. P
❑WUP ❑Checklists ❑Design ❑Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. [:]Yes [�-No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes ANo
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? [:]Yes No
❑ NA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑NA ❑NE
❑NA ❑NE
Page 2 of 3 21412014 Continued

Facili Number: - Date of Inspection:
24. 6id the facility fail to calibrate waste application equipment as required by the permi . ❑ Yes 0 No ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes R No ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge? ❑ Yes JZ No ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes O No ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes o ❑ NA ❑ NE
and report mortality rates that were higher than normal?
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)
T
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Yes
No
❑ NA ❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
jo
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
No
❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
No
❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
R�No
❑ NA ❑ NE
Comments (refer to question ft Explain any YES answers and/or any additional recommendations or_any other comments..
Use drawings of facility to better explain situations (use additional pages as necessary).
7-1
Reviewer/Inspector Name: & A?
Reviewer/Inspector Signature:
Page 3 of 3
Phone: U
Date: If
1214110,74

Reason for Visit: GrRoutine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: ' `- j Departure Time: County: Region:
Farm Name: cJ �- 4 ) E1 n cA[ ra_/- -44-- % -1 Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Phone:
Facility Contact: j Title: Phone:
Onsite Representative: ��` (� �.{� % Integrator: l
lz�
Certified Operator: Certification Number:
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
Design Current
Swine C+apacity Pop.
Wean to Finish I
Design Current
Wet Poultry Capacity Pop.
I Layer IDairy
Cattie
Cow
Design Current
Capacity Pap.
Wean to Feeder
I
INon-Layer
I
EEI
Da"j Calf
Dairy Heifer
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Design Current
D , P,ouI Ca aci P,a P.
ILayers I
Dry Cow
Non -Dairy
Beef Stocker
Gilts
Non -La ers
Beef Feeder
Boars
Pullets
Beef Brood Cow-4—
Other
Other
Turkeys
Turkey Poults
Other
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation? ❑ Yes Po ❑ NA ❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made? ❑ Yes JoNo ❑ 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-IEPNo [3 NA ❑NE
❑ Yes J:a No ❑ NA ❑ NE
❑ Yes 0 No ❑ NA ❑ NE
Page 1 of 3
21412014 Continued

Facility Number: -ar7rT Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
No
❑ NA ❑ NE
25•Is the facility out of compliance with permit conditions related to sludge? If yes, check
❑ Yes
No
❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge?
❑ Yes
No
❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
❑ Yes
SZ No
❑ NA ❑ NE
Other issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
❑ Yes
PKNo
[DNA
❑ NE
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
[] Yes
&No
❑ NA
❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
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
PrNo
❑ NA
❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
f No
❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
ENo
❑ NA
❑ NE
Comments (refer to question -#) Explainany-YES,answersrand/or any add tional;recommendat►ons or an other comments
.
Use drawingsoffacihY to better ag_ , b,ayJs." Plam sitnaPions (use additional•p ges neee ' scary) ;,- �� � � • F. ��,�,. � . &� �:'` _ °��� .
Pff//3 ecle'�4 'qd­ 6CICela
tJlnc�ow 61 o2da�s,�
14 7-­?--
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone:
Date: 5�4 Z�z
121412114

Facility Number: -
Date of Inspection: L
Waste Cbllection & 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:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes rNo ❑ NA ❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a ❑ Yes ;No [DNA ❑ 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 X0 No ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes FZrNo ❑ 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 0 No ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes E�No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
I ,j No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
T�'o
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
ZNo
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
j No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
ONo
r
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
6o
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
ZN,o
❑ NA
❑ NE
the appropriate box.
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements
❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below.
JZ Yes
❑'No
❑ NA
❑ NE
❑ Waste Application ❑ Weekly Freeboard Waste Analysis ❑ Soil Analysis
❑ Waste Transfers
❑ Weather Code
to
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V Rainfall Inspections
❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge?
❑ Yes
No
❑ NA
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
[:]Yes
YNo
❑ NA
❑ NE
Page 2 of 3
21412014 Continued

Type of Visit: j0<ompliance 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 0 Denied Access
Date of Visit: Arrival Time: Departure Time: O County:
Farm Nai Owner Email:
Owner Name:
Mailing Address:
Physical Address:
Facility Contact:
.r-
Onsite Representative: , )ze Sh2
Certified Operator:
Back-up Operator:
Location of Farm:
Phone:
Title:
Phone:
Integrator:
Certification Number:
Certification Number:
Latitude: Longitude:
Region:
Design Current Design Current
Swine Capacity Pop. Wet Poultry Capacity Pop.
inish La er
Design Current
Cattle Capacity Pop.
Dai Cow
eeder
Non -La er
Dai Calf
Finish
Wean
Feeder
Finish
W
Design Current
D , P,oult�, Ca aci P.o
La ers
Non -Layers
Dai Heifer
D Cow
Non -Dairy
Beef Stocker
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turke s
Other Turke Poults
Other Other
Discharges and Stream Impacts
I. Is any discharge observed from any part of the operation? ❑ Yes ff No ❑ NA ❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was, the conveyance man-made? ❑ Yes EfNo ❑ NA ❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ) ❑ Yes ZNo 0 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 ENo
❑ Yes �No
❑ Yes dNo
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Page 1 of 3 j 21412011 Continued

Facility Number: - Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes T❑�No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes 0'N- o ❑ 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 ff 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 J�fNo ❑ 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 0 No
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes WNo
❑ 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 [�j No
❑ NA
❑ NE
maintenance or improvement?
T
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
❑ NA
❑ NE
maintenance or improvement?
J�TNo
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes ZNo
❑ NA
❑ NE
❑ Excessive Pending ❑ 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 0 No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes No
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes Z] No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes ,Ej No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes Ej No
❑ NA
❑ NE
the appropriate box.
❑WUP ❑Checklists ❑Design [:]Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes ZI No
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections [:]Monthly and 1" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes Z No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes EfNo
❑NA ❑NE
❑ Weather Code
❑ Sludge Survey
❑NA ❑NE
❑ NA ❑ NE
Page 2 of 3 21412011 Continued

Facility Number: Date of inspection:
24,.Did the facility fail to calibrate waste application equipment as required by the permit. V ❑ Yes [''No ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes �ZNo [] NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey [:]Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge?
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
❑ Yes 0 No ❑ NA ❑ NE
❑ Yes [2rNo ❑ NA ❑ NE
❑ Yes PrNo ❑ NA ❑ NE
❑ Yes jo No ❑ NA ❑ NE
0 Yes 'Z No ❑ NA ❑ NE
❑ Yes ;2"'No ❑ NA ❑ NE
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes ZNo ❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes 0 No ❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency? ❑ Yes ,Ej No ❑ NA ❑ NE
Comments (refer to question #): Explain any YES answers and/or any additional recommendations or any other comments.
Use drawings of facility to better explain situations (use additional pages as necessary).
_rG� IL77
�ulY G.6�
' �3e Sine. -6 & sI e SC,erV 44,)ts Ye;Lr
Reviewer/Inspector Name: O (� �,p Phone: 7 7(�
Reviewer/Inspector Signature: Date. -2
Page 3 of 3 2/4 011

Fac> hty NuiiihR -
f
'Division of
0 Division of
- ��bOther Age
tter Qoalrty
it and Water Conservation
Type of Visit .6dompliance Inspection O Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit eRoutine O Complaint O Follow up O Referral O Emergency O Other ❑ Denied Access
Date of Visit: �Vo
ivalTiime: Departure Time: �County: � Region:Farm Name:
Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: ? Title: ,,,. Phone No:
Onsite Representative: � e `��� �Integrator: _2me
Certified Operator: Operator Certification Number:
Back-up Operator: Back-up Certification Number:
Location of Farm: Latitude: = o [= 6 0 i! Longitude: = o [----] ,
Design .,Current`
Swine r Capacity Population
u
❑ Wean to Finish ❑
❑ Wean to Feeder
❑ Feeder to Finish
❑ Farrow to Wean
'
❑ Farrow to Feeder
❑ Farrow to Finish
rs
❑ Gilts
❑
❑ Boars
' ❑
1Other4 `
Other [ [
Non -Layer
I
LI Dairy Calf
❑ Dairy Heifer
Dry Poultry0"
D Dry Cow
-��rr
✓,
El Non -Dairy
Layers
❑ Beef Stocker
Non -Layers
❑ Beef Feeder
Pullets
❑ Beef Brood C
Turkeys
Turkey Poults
r
OtherNii
beryof�
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 PNo ❑ NA ❑ NE
❑ Yes ❑ No
❑ NA
❑ NE
❑ Yes []No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes )3*'No
❑ Yes XNo
❑ NA
❑ NE
❑ Yes Q<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?
Struc re 1 Structure 2 Structure 3 Structure 4
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): !�
5. Are there any immediate threats to the integrity of any of the structures observed?
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
through a waste management or closure plan?
❑ Yes /, No
❑ Yes ZNo
Structure 5
❑ NA ❑ NE-
❑ NA ❑ NE
Structure 6
❑ Yes JXNo ❑ NA ❑ NE
❑ Yes KNo ❑ NA ❑ NE
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes EfNo ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes VrNo ❑ 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 ;2�No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes [2 No ❑ NA ❑ NE
maintenance/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes ONo ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
12. Crop type(s)
13. Soil type(s)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
E�rNo
❑ NA
.❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
Plio
❑ NA
❑ NE
16, Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
❑ Yes
;VNo
❑ NA
❑ 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
O'No
❑ NA
❑ NE
Comments (refer to question #): Explain any YES answers,and/or any recommendations or,any other comments y
Ilse- drawings of facility to better explain situations. (use additional pages as necessary):
Reviewer/Inspector Name Phone: j
Reviewerllnspector Signature: ��/ �Z�� Date: ll
Page 2 of 3 12728104 ' Continued

Faciliiy 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 VNo ❑ NA ❑ NE
the appropriate box. ❑ WUp ❑ Checklists ❑ Design El Maps El Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes ;/No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and I ° Rain Inspections ❑ Weather Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
ZNo
❑ NA
❑ NE
23,
if selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
No
TT�No
El NA
El NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
El Yes
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
o
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
No
❑ NA
❑ NE
Other lssues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
gNo
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
EiNo
❑ 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
VfNo
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
3 L
Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
X o
❑ NA
[INE
General Permit? (ie/ discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
ElYes
No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
PNo
❑ NA
❑ NE
Additional Comments and/or Drawings:
Page 3 of 3 12128104

Type of Visit: ® Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
Reason for Visit: 0 Routine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: :off Departure Time: County:
Farm Name: Oyu, Owner Email:
Owner Owner Name: O -e Sti�'�-p /�,� _ _ Phone:
1/00GT.) Region:
Mailing Address:
Physical Address: f
Facility Contact: 7 Div Title: Phone:
Onsite Representative: 1�, ��/ Integrator: =;2 � I 7_ 4� 6-L-Q
Certified Operator:
Back-up Operator:
Location of Farm:
Latitude:
Certification Number:
Certification Number:
Longitude:
Swine
Wean to Finish
Design Current
C•apaciiy Pop.
Wet Poultry
La er
Desiga
Capacity
Current
Pop.
Cattle
Dairy Cow
Dairy Calf
Design Current
Capacity Pop.
Wean to feeder 2 oc7 pp
Non -La er
Feeder to Finish
Dai Heifer
Farrow to Wean
D . $oultr.
La ers
Design
C•_a aci
Current
Pio ,
D Cow
Farrow to Feeder
Farrow to Finish
Non -Dairy
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Other
L_jOther
Turke s
Turke Poults
Other
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWR)
c. What is the estimated volume that reached waters of the State (gallons)?
❑ Yes
� No
❑ NA
❑ NE
❑ Yes
❑ No
n NA
❑ NE
[:]Yes
[:]No
0 NA
❑ NE
d. Does the discharge bypass the waste management system? (If yes, notify DWR) Lj Yes 0 No M NA ❑ NE
2. Is there evidence of a past discharge from any part of the operation? ❑ Yes MNo ❑ NA ❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters ❑ Yes `P No ❑ NA ❑ NE
of the State other than from a discharge?
Page I of 3 21412015 Continued

"2 1
kaeflity Number: 61 - Date of Ins ection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes r No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No 21 NA ❑ NE
Structure
---F--- Structure 2
Identifier:
Spillway?:
Structure 3 Structure 4 Structure 5 Structure 6
Designed Freeboard (in):
y
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes No ❑ NA ❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a ❑ Yes U� 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 [P)No ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes No ❑ NA ❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require ❑ Yes No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes No ❑ NA ❑ NE
maintenance or improvement? 0
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes 0 No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN [] PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of fWind Drift[ ❑ Ap lication Outside of Ap roved Area
12. Crop Type(s):A45�( r ��
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 No ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable ❑ Yes No ❑ NA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
18. Is there a lack of properly operating waste application equipment?
Reauired Records & Documents
❑ Yes No
❑ Yes No
❑ NA ❑ NE
❑ NA ❑ NE
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes TSNo ❑ 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. r
❑WUP El Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes 1P No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis 0 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 No ❑ NA ❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes No ❑ NA ❑ NE
Page 2 of 3 21412015 Continued

Facili Number: - Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit. [:]Yes " No ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes No ❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge? ❑ Yes EjNo ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes 10 No ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
[] Yes
RP 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
�q No
[DNA
❑ NE
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
❑ Yes
No
❑ NA
❑ NE
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Yes
No
❑ NA
❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
M No
❑ NA
❑ NE
33. Did the Reviewer/inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
No
❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
[K) No
❑ NA
❑ NE
Reviewer/Inspector Name:
Reviewer/Inspector Signature
Page 3 of 3
Phone: fp iP ',134"9
Date: %
21412015

Type of Visit �
Reason for Visit
Date of Visit:
Farm Name:
Owner Name:
Mailing Address:
Physical Address:
Compliance Inspection 0 Operation Review 0 Structure Evaluation 0 Technical Assistance
E) Routine 0 Complaint 0 Follow up 0 Referral 0 Emergency 0 Other ❑ Denied Access
Arrival Time: / Q Departure Time: County: 1 Region: \L_.,X_d7e
Facility Contact: A- Title:
On site Representative:
Certified Operator:
Back-up Operator:
Location of Farm:
Swine
Owner Email:
Phone:
,Phone No:
Integrator:
Operator Certification 1 umber:
Back-up Certification Number:
Latitude: = o ❑ , Longitude: = 0 = 1
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer
6 ❑ Non -La es
❑ Wean to Finish
Wean to Feeder
❑ Feeder to Finish
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
Other
❑ Other
Dry Poultry
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turke s
❑ Turkey Poults
❑ Other
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
Design Current
Cattle Capacity Population
❑ Dairy Cow
❑ Dairy Calf
❑ Dairy Heifer
❑ 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 2rNo ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
.�No
❑ NA
❑ NE
❑ Yes
No
❑ NA
❑ NE
12128104 Continued

Facility Number• — Date of Inspection f6d
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes ;2 o ❑ 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 ZNo ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.) �r
6. Are there structures on -site which are not properly addressed and/or managed El Yes �E 1 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 ,a No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes .INo ❑ 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 ONo ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes 2fNo ❑ 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 ❑ PAN > 10% or 10 Ibs [:]Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Ac le Crop Window Evidence of Wind Drifl ❑ Application O ide of Area
12. Crop type(s) / A J�7
13. Soil type(s) Q
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes Z No
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes j2rNo
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination'❑
Yes 2rNo
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes K o
❑ NA
El NE
18. Is there a lack of properly operating waste application equipment?
ElL1 No Yes
❑ NA
❑ NE
Reviewer/Inspector Name
Phone:
Reviewer/Inspector Signature:
Date: F& P Af ,S
12/28/ 4' f Continued

Facility Number: 3 Date of Inspection r
Re uired Records & Documents
1�. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes XNo ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes ZNo ❑ NA ❑ NE
the appropirate box.
❑ WUP ❑Checklists El Design ❑Maps El Other
21.
Does record keeping need improvement? If yes, check the appropriate box below.
XYes
[:]No
❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis
❑ Waste Transfers
❑ Annual
Certification
Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1 " Rain inspections ❑
Weather Code
22.
Did the facility fail to install and maintain a rain gauge?
E Yes
❑ No
❑ NA ❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes
❑ No
,ONA ❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
❑ No
ONA ❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
❑ No
ZNA ❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes ,,Z No
❑ NA ❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
❑ No
❑ NA 21NE
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 .ETNo
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes Z/ No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
31. Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes -dNo
❑ 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 0*—No
❑ NA
❑ NE
33. Does facility require a follow-up visit by same agency?
❑ Yes ;�K
❑ NA
❑ NE
Additional Comments and/or Drawings:
? 142jCk C-40 YV OL5
a+ Ca c In
CGfrevtf
12128104

(Type of Visit Compliance Inspection O Operation Review O lagoon Evaluation
Reason for Visit .Routine O Complaint O Follow up O Emergency Notification O Other ❑ Denied Access
Facility ?Number g Date of Visit: 4�14Tune: .10
01
_ 10 Not Operational O Below Threshold
.'PermittedATCertified 0 Condi •onally Certified 0 R ' tered Date -Last Operated or Above Threshold:
Farm Name: a �.� /� Cou�t_v:
Owner Name: _ . _W . _ , 'Phone No:
Mailing Address:
Facility Contact: _- ---- - - . Title• ___ _ _ Phone No:
Onsite Representative: _ , _ , , Integrator.
Certified Operator:. _ , , _ , Operator Certification Number:
Location of Farm:
Swine iWouitry ❑ Cattle ❑ Horse Latitude • &4 Longitude a <
Discharees & StreamImpa
1 _ Is any discharge observed from any part of the operation? ❑ Yes ZNo
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made? ❑ Yes ❑ No
b. If discharge is observed, did it reach Water of the State? (If yes, notify DWQ) ❑ 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 Jallo
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes E No
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway ❑ Yes O'Iqo
Struct}�re 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: .. _ l _ . aw,
Freeboard (inches):
12112103 Continued

Facility Number: 3 j — Date of Inspection
5. Are'there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, ❑ Yes )!fNo
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or
❑ Yes.-ErNo
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 {TNo
8. Does any part of the waste management system other than waste structures require maintenancerimprovement? ❑ Yes ,®'No
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
❑ Yes
eNo
elevation markings?
Waste AQylication
10. Are there any buffers that need maintenance./improvement?
❑ Yes
ZNo
I I . Is there evidence of over application? If yes, check the appropriate box below.
❑ Yes
ENo
❑ Excessive Ponding ❑ PAN Hydraulic Overload ❑ Frozen Ground ❑ Copper and/or Zinc
12. Crop type
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)?
❑ Yes
'awo
14. a) Does the facility lack adequate acreage for land application?
❑ Yes
eNo
b) Does the facility need a wettable acre determination?
❑ Yes
EI No
c) This facility is pended for a wettable acre determination?
❑ Yes
Ejl1 o
15. Does the receiving crop need improvement?
❑ Yes
O ivo
16. Is there a lack of adequate waste application equipment?
❑ Yes
01 o
Odor Issues
17. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below
❑ Yes
.0"No
liquid level of lagoon or storage pond with no agitation?
18. Are there any dead animals not disposed of properly within 24 hours?
❑ Yes
'ErNo
19. Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt,
❑ Yes
2 No
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
Zl�o
Air Quality representative immediately.
--:;ALL-�
Coxn�eats (refer to goon} lcplam any lrEsaras�vers aadlr airy aapotler mats.
nor
aUs d nos of fa ztm �P D ❑ Feld Copy ❑ Final Notes
-:, � -. � _,:.. ����. d� - --- tea... , .. � .._ �` �.... .�:_�� �� -•-
G�
ReviewedinspectorName;°
Reviewerihmpector Signature: Date: U
12112103 Con inued

Facility Number: 3 - Date of inspection 0
Required Records & Documents
21. Fail to have Certificate of Coverage & General Permit or other Permit readily available?
22. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.)
23. Does record keeping need improvement? If yes, check the appropriate box below.
❑ 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?
25. Did the facility fail to have a actively certified operator in charge?
26. Fail to notify regional DWQ of emergency situations as required by General Permit?
(ie/ discharge, freeboard problems, over application)
27. Did Reviewer/inspector fail to discuss review/inspection with on -site representative?
28. Does facility require a follow-up visit by same agency?
29. Were any additional problems noted which cause noncompliance of the Certified AWMP?
NPDES Permitted Facilities
30. Is the facility covered under a NPDES Permit? (If no, skip questions 31-35)
31. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
32. Did the facility fail to install and maintain a rain gauge?
33. Did the facility fail to conduct an annual sludge survey?
34. Did the facility fail to calibrate waste application equipment?
35. Does record keeping for NPDES required forms need improvement? If yes, check the appropriate box below.
❑ Stocking Form ❑ Crop Yield Form ❑ Rainfall ❑ Inspection After 1 " Rain
❑ 120 Minute inspections ❑ Annual Certification Form
❑ Yes 'PO3Qo
❑ Yes ETNo
❑ Yes 01 o
❑ Yes ZNo
❑ Yes ONo
❑ Yes ❑ No
❑ Yes �Ofio
❑ Yes ,Z No
❑ Yes 9110
❑ Yes 0-<o
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
12112103

G DivisioUW4ter". Quality
Q,:Dtnston of Soil.and..WaEer Conservation
_ 00
- Agency
Type of Visit rompliance Inspection O Operation Review O Lagoon Evaluation
Reason for Visit A Routine O Complaint O Foitow up O Emergency Notification O Other ❑ Denied Access
Facility Number EZPDate. of Visit: Time: [� Printed on: 7/21/2000
Not O eratiorai O Below Threshold
Permitted [] Certified Eq Conditionally Certified ❑ Registered Date Last Operated or Above Threshold
Farm Name: ..r. ....... County :..............
.........................
OwnerName �.coE ............... Ll >.................................................. Phone No:.......................................................................................
Facility Contact:
Mailing Address: .................................
Onsite Representative:..r, ..R.,
Certified Operator:
Location of Farm:
Title: ..................................... .......................... Phone No:.........................
......................................................................................................................... ......... .................
....................................... Integrator: ....../i 0 �v y ................. ........................
,...... Operator Certification Number:
Swine ❑ Poultry ❑ Cattle ❑ Morse Latitude �• �� ��� Longitude �• ��°
Design Current Design Current Design. Current
Capacity Po elatiCapacity Population Ca cAi6nlation
onPouttry Cattle
Wean to Feeder ❑Layer ❑Dairy
Feeder to Finish ❑ Non -Layer ❑ Non -Dairy
` Farrow to Wean
Farrow to Feeder ❑Other
Farrow to Finish Total Design Capacity
�- Gilts
Boars Total SSLW
�, .,Number ol" I,agooas Subsurface Drains Present ❑ Lag�►n Area ❑ Spray Field Area
�w'y._ --
�Own Ponds / So1xd Ttraps No Liquid Waste Management System
,.. _
Dischai•Ees & Stream ImaacEs
1. Is any discharge observed from any part of the operation?
Discharge originated at: ElLagoon [ISpray Field ❑ Other
a. If discharge is observcd, 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/ruin?
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 ; Structure 4 Structure S
❑ Yes FrNo
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes �No
❑ Yes yNo
❑ Yes XNo
Structure 6
Identifier: .........................................................................................................
Freeboard (inches): 54
5100
Continued on back

Facility Number: Date of Inspection
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 maintenancelimprovement?
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 Pon9ling ❑ PAN ❑ Hydraulic Overload
12, Crop type
13. Do the receiving crops differ with those designated in the/Certified Animal Waste Management Plan (CAWMP)?
14. a) Does the facility lack adequate acreage for land application?
b) Does the facility need a wettable acre determination?
c) This facility is pended for a wettable acre determination?
15. Does the receiving crop need improvement?
16. is there a lack of adequate waste application equipment?
Required Records & Documents
17. Fail to have Certificate of Coverage & General Permit readily available?
18. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.)
19, Does record keeping need improvement? (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 *iolotiolis:eF' dtf 1*j10e� VKce h ed d�ri 4g �his:vjjsjt; • Y;o0 ivitj •tei " WO do fu4 t��r . :
carrkinot deitce: ahaut: this vi�sit� .......:::..:....... . ............... .
❑ Yes No
❑ Yes Q( No
❑ Yes No
❑ Yes No
❑ Yes No
❑ Yes o
❑ Yes No
❑ Yes ANo
❑ Yes Z No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes (Q No
❑ Yes /� No
❑ Yes No
❑ Yes No
❑ Yes /� No
❑ Yes No
❑ Yes
❑ Yes No
❑ Yes No
c
❑ Yes No
❑ Yes No

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 at/or below ❑ Yes JE(No
liquid level of lagoon or storage pond with no agitation?
27. Are there any dead animals not disposed of properly within 24 hours? ❑ Yes No
28. is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt, ❑ Yes �o
roads, building structure, and/or public property)
29. Is the land application spray system intake not located near the liquid surface of the lagoon? ❑ Yes '1!-3"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 N "o
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'J�o
Addifiouomrnents an or Drawings:-
- ,-JAJ
-
5/00

LXN
-
Dtvrsron of Water Qual>Ity
-
r
tD Division of Soil and Water Conservation
J
Q Agency
k
- #
:Other
Type of Visit Compliance Inspection Q Operation Review O Lagoon Evaluation
Reason for Visit Routine
O Complaint O Follow up p Emergency Notification
Q Other
❑Denied Access
Facility Number Bate of Visit: ��Time: 1 dG Printed on: 7/21/2000
Q Not O erational Q Below Threshold
)&ermitted [j Certified p Conditionally Certified © Registered Date Last Operated or Above Threshold
Farm Name: [....... _.... U �-- ..7 .........................._._........... ).. �1.." �� - ......•1................................. County•
Owner Name :.....................................
Facility Contact:
Title:
MailingAddress: ...................................................... f...-.... ...... .-...................
Onsite Representative: .......... .....
Certified Operator:
Location of Farm:
Phone No:
Phone No:
..................................................................................... ..........................
Integrator:.,..„..
... Operator Certification Number:
fT
❑ Swine ❑ Poultry ❑ Cattle ❑ Horse Latitude Longitude
Design Current Design Current Design Current
Swine Capacity Population Poultry Capacity Population Cattle Capacity Population
tE�Wean to Feeder Ga I JE] Layer I I I JE] Dairy
❑Feeder to Finish 10 Non -Layer I I JE] Non -Dairy
❑ Farrow to Wean
❑ Farrow to Feeder ❑ Other
❑ Farrow to Finish Total Design Capacity
❑Gilts
El Boars Total SSLW
Number of Lagoons ❑ Subsurface Drains Present 110 Lagoon Area ❑ Spray Field Area
Holding Ponds 1 Solid Traps JCI No Liquid Waste Management System
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
ONo
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. if discharge is observed, was the conveyance man -nude'?
❑ Yes
❑ No
b- If discharge is observed, slid it reach Water of the State" (If yes, notify DWQ)
❑Yes
❑ No
c. II' discharge is observed. what is the estimated 11ow in gal/trim?
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
XNo
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes
[�No
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway
❑ Yes
A No
Structure I Structure 2 Structure ; Structure 4 Structure 5
Structure b
Identifies:................................................................
Freeboard (inches):
5/00
Continued
on back

Facility Number: 1 — 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? ❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload
12. Crop type
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)?
14. a) Does the facility lack adequate acreage for land application?
b) Does the facility need a wettable acre determination?
c) This facility is pended for a wettable acre determination?
15. Does the receiving crop need improvement?
16. Is there a lack of adequate waste application equipment?
Required Records & Documents
17. Fail to have Certificate of Coverage &_ General Permit readily available?
18. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.)
19. Does record keeping need improvement? (le/ 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?
atitjns:o"r• de- epe. tcies were notes- during "is:visit: - Yop :will-e&-6ye Rio #'ui• &
• corresp6Tideiice: aboitt this .visit ...... _ _ ... _
❑ Yes *0
❑ Yes �(No
❑ Yes �No
❑ Yes )<No
WYes ❑ No
❑ Yes XNo
❑ Yes J?:q No
❑ Yes tRf'No
❑ Yes NrNo
❑ Yes j YNo
❑ Yes WNo
❑ Yes WNo
❑ Yes OfNo
[-]Yes X No
❑ Yes t(No
XYes ❑ No
❑ Yes &No
❑ Yes J'No
❑ Yes N�No
❑ Yes D'No
❑ Yes M No
❑ Yes 9No
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):
PAL
ReviewerAnspector Name �t�r 3 q� x —'D'0'6
ReviewerAnspectorSignature: Date: --ro1 rGG 5100

Facility Number: —�jl! Date of Inspection 1 c° 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 1Jor below XYes ❑ 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 kNo
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 )SI 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 J$1 No
31. Do the animals feed storage bins fail to have appropriate cover? ❑ Yes Cif No
32. Do the flush tanks lack a submerged fill pipe or a peimanent/temporary cover? ❑ Yes WNo
J
5100

Lagoon Dike Inspection Report
b '�
Name of Farm/Facility
J
Location of Farm/FaciIity
IL. $ , e o
o o
�t---
Owner's Name, Address
, oe f �� o �e Z� U
and Telephone Number
t),-,11.'L �1��
Date of Inspection
o? 4 7 �J Names of Inspectors
yt O
Structural Height, Feet
3 Freeboard, Feety
Lagoon Surface Area, Acres
�P2 c c Top Width, Feety
!
Upstream S1ope,xH:1V
r}
� • l Downstream Slope, xH:1V
Embankment Sliding?
Yes No
(Check One, Describe if Yes)
Seepage?
Yes No - - - 42 Poe,
h
ja � e-
(Check One, Describe if Yes)
j
- e /C
Erosion?
Yes No
(Check One, Describe if Yes)
Condition
of
e) v
Vegetative Cover
(Grass, Trees)
Did Dike Overtop?
Yes _)�: No If Yes, Depth of Overtopping, Feet
Follow -Up Inspection Needed? Yes No
Engineering Study Needed? Yes >4— No
Is Dam Jurisdictional to the Dam Safety Law of 1967?
Other Comments
Yes
No
%-/T i r it

yol'iS-C
C26cl 101*

..�.... _.�., �.._. s.. ..a _.._.�._... _�--.-w�__..�-'"_'___' _._��:.. �.., rr•..�}:�:-ris�1;=�-;-..>?/�:=f...itrr'�:.=r..,.a_�_...�..�:..�-.,.,�--.._._�_,.. a_..+s ..ss� -..s_. __ .___....
..Lagoon Dike Inspection Report
Name of Farm/Facility
Location of Farm/Facility S �J e or
lie
Owner's Name, Address
and Telephone Number
Date of inspection
Structural Height, Feet
Lagoon Surface Area, Acres
Upstream Slope,xH:IV
�4C f 0C­ , < k C 1e_ )0-10 N
e_ /0 a Ell r Tv�
o? 4 7 �% Names of Inspectors , ,yy O
_�C ViC2o�
Freeboard, Feet
SP2 c c Top Width, Feety
n r
Downstream Slope, xH:IV
Embankment Sliding? Yes No
(Check One, Describe if Yes)
Seepage? Yes -No ta5Qk— Pe �5 10 � e
(Check One, Describe if Yes) -� - --1 � r C y
-� x GC,
Erosion? Yes �/ No
(Check One, Describe if Yes)
Condition of
Vegetative Cover
(Grass, Trees)
Did Dike Overtop?
Follow -Up Inspection Needed?
Engineering Study Needed?
Yes : No If Yes, Depth of Overtopping, Feet
Yes No
Yes 7_ No
Is Dam Jurisdictional to the Dam Safety Law of 1967? Yes No
r �} L
Other Comments i_t�
h Q C Q

docl r

Facility Number Date of Inspection
Time of inspection ® 24 hr. (hh:mm)
■ Permitted p Certified 0 Conditionally Certified p Registered Not peratrona Date Last Operated:
Farm Name: JAJQ.Sho1ax:F.arm..#4............................................................................... County: Duplin WIRO
Owner Name: Jot.&.Dwight..................... Shnlar..........
FacilityContact: ......................................................................
Mailing Address: .1.44R.. aep.Boxto�m..Raad..................
Onsite Representative: ..........................................................
Certified Operator:druc.0...............
Location of Farm:
..... Phone No: 9111:25S-3519.....
Title: ............................................. ..... Phone No: ............. .......
Warllacz.NC............................................................ 284Gbr..............
Integrator: Mut:phy..F.amily.Farms..........................
Sholar............................................... Operator Certification Number:17.982..........
Latitude ®•®° ®« Longitude ©• ®� ®{
L
Swine
Design Current Design _ :-Current Design Current
Capacity,Populatron..T Poultry Capacity -Population Cattle,` Capacity Population
® Wean to Feeder
2600
❑ Feeder to inrs
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
Boars
Number of -Lagoons _ ' m ❑Subsurface rains resent ❑ agoon rea ❑ pray re rea
Holdmg.`Ponds / Sohd Traps: E3 o LiquidWaste Management System
_ .
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation? ❑ Yes ❑ No
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made? ❑ Yes ❑ No
b. If discharge is observed, did it reach Water of the State? (If yes; notify DWQ) ❑Yes p 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 0 No
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? 0 Yes []No
Waste Collection & Treatment
4. is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway p Yes []No
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure G
Identifier:
Freeboard(inches): ...............3.1...............................42.......................................................... .......... ..........
5. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion,
3/23/99 seepage, etc.)
[:]Yes ❑ No
Continued on back

Faci ity Number: 31_855 Date of Inspection
• 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?
p Yes
❑ No
9.
Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
elevation markings?
[]Yes
❑ No
Waste Application
10.
Are there any buffers that need maintenance/improvement?
[]Yes
❑ No
11.
Is there evidence of over application? []Excessive Ponding ❑ PAN
❑ Yes
[]No
12.
Crop type
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?
Req"ired Records & Documents
17. Fail to have Certificate of Coverage & General Permit readily available?
18. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.)
19. Does record keeping need improvement? (ie/ irrigation, freeboard, waste analysis & soil sample reports)
20. Is facility not in compliance with any applicable setback criteria in effect at the time of design?
21. Did the facility fail to have a actively certified operator in charge?
22. Fail to notify regional DWQ of emergency situations as required by General Permit?
(ie/ discharge, freeboard problems, over application)
23. Did 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?
. .... patio . .. cl. ...ncres.we . ..o...during: this ..visit.�au will receive ..further.. .
.... Wok this *visit.
:: : :::::: ::: :
cane
ient freeboard available. No problems detected
p Yes ❑ No
❑ Yes ❑ No
❑ Yes []No
❑ Yes []No
❑ Yes []No
❑ Yes []No
p Yes ❑ No
p Yes p No
[]Yes []No
[:]Yes ❑ No
[]Yes p No
❑ Yes ❑ No
❑ Yes []No
❑ Yes ❑ No
p Yes ❑ No
lannon-DSW): Lagoon appears to be excavated in clay, excellent condition all around dike. Dike wall in tact and not saturated.
ufficient freeboard. No further recommendations
Reviewer/Inspector Name 1GrcVicker _ Brian -Gannon (DSW) -�
Reviewer/Inspector Signature: Date:

Revised April 20, 1999
JUSTIFICATION & DOCUMENTATION FOR MANDATORY WA DETERMINATION
Facility Number Operation is flagged fora wettable
Farm Name:._ �-�r Sa.Y'� acre determination due to failure of
On -Site Representative: Part 11 eligibility items) F1 F2 F3 F4
Inspector/Reviewer's Name:
Date of site visit:
Date of most recent WUP: ��
Annual farm PAN deficit: 13 pounds
Operation not required to secure WA
determination at this time based on
exemption F1 ,E2 fQ=_3:';N E4
Operation pended for wettable acre
determination based on P1 P2 P3
6rigation Systems)circle -#: I. hard -hose traveler; 2. center -pivot system-}; 3. linear -move system;
stationary sprinkler system wlpermanent pipe; 5. stationary sprinkler system .w/portable pipe;
6. stationary gun system w{permanent pipe; 7. stationary gun system w/portable pipe
PART I. WA Determination Exemptions (Eligibility failure, Part 11, overrides Part I exemption.)
E1 Adequate irrigation design, including map depicting wettable acres, is complete
and signed by an I or PE.
E2 Adequate D, and D203 irrigation operating parameter sheets, including M. ap
depicting wettable acres, is complete and signed by an I or PE.
V E3 Adequate D, irrigation operating parameter sheet, including map depicting
wettable acres, is complete and signed by a WUP.
E4 75% rule exemption as verified in Part III. (NOT E:75 % exemption cannot be
applied to farms that Tall the eligibility checklist in Part It. Complete eligibility
checklist, Part 11 - F1 F2 F3, before completing computational table in Part III).
PART 11.75% Rule -Eligibility Checklist and -Documentation of WA Determination
Requirements. WA Determination .required .because_ operation fails :one of the .eligibility
requirements listed below:
F1 .Lack.or�acreage_wnicn-resulted inz)ver.-applicauon7nf-wastewater_(PAN) on:spray-
field(s):accardingiolarm'sdasttwoyearsmf-'rmaationa cords.--.
i=2 Unclear, -illegible; or lack of inforrnationimap.
F3 Obvious 7jeld:fimitations-(numerous itches;:Fii]Lrrezo=deductu-equired=..__.
buffer/setbackmcreage; or25°/a:ofiotal:acreageddeniirrdddri_CAWI Fi -.includes
small, -irregularly -shaped -flelds Fields:Eessthan-fields-travelers:or.less#han
2 acresfor.stationaryzprinkiers).
F4 WA determination required because CAWMP credits -fieid(s)'s acreage:in excess
of 75% of the respective field's total acreage as noted in table in Par III.

Revised April 20, 1999
Facility Number
Part Ill. Field by Field Determination of 75% Exemption Rule for WA Determination
TRACT
NUMBER
-
FIELD
NUMBER',2
TYPE OF
IRRIGATION
SYSTEM
TOTAL
ACRES
CAWMP
ACRES
FIELD
%
COMMENTS3
t
i
and type of irrigation -system. - if pulls, etc. cross -more -than -one field, inspectorireviewer will have to combine fields to
Calculate 7:5°6 geld by field determinationior exempiian,-otherwise operatlon will be subject to WA determination.
F1_LD NUMBER' - most be clearly delineated on -map.
COMMENTS'- hack -up fields with CAWMP acFeage_exceeding75% of its total:acres -and raving received less .than 50%
of its annual PAN as -documented inthe larm's previous-twoyears'(1997 & 1998) of irrigationTecords,­cannot serve -as -the
sole basis-forreouiring a WA Determination_:..Back-upfields must-benoted in the -comment mez-bon and mustbe accessible
by irrigation -system.
:=,art IV. Pending WA-Determinations-
P1 Plan Jacks.foIlowing:information:
P2 Plan Tevision -may.satis y75% rule based on adequate overall PAN deficit -and by
adjusting -all fRld :acreageao-below 75% use rate _
P3 Other (ielin process of installing new irrigation system)-

-� Division of Soil an&Wat6t, Conservation ?.Operation Reveew
- Division of Soil and=Water Conseryatton . Compliance lnspect�on -
J79Dnrision of Water Quality Compliance inspechoa -
13:Otfter�Agency Operation=lie+vrew_ a
RD Routine 0 Com taint 0 Follow-up of DWR inspection 0 Follow-up of DSWC review 0 Other
Facility Number Date of Inspection - -
Time of Inspection
Permitted A Certified [j Conditionally Certified © Registered
Farm Name: .. .d =T...� 1' ... ../..... I—......
Owner Name:............7�?!./Il?.......�1................
Facility Contact: ............ �i'1.-'.................................. Title:................. .
:Mailing Address: ....../...H .....j .. i�..../.ct 4.rJ P�.:....& .......
.... .............
Onsite Representative: �Q�----- �4e
Certified Operator: ..... ,r�jQ,.r....Lr.'.................�1YD•-,.: .. .........................
Location of Farm: _
24 hr. (hh:mm)
Not Operational 1 Date Last Operated: ..........................
County: ....... .r)dADL11PAj .........................
Phone No: ........ .1�.10......2-� �M-71 ......
.................................... Phone No:.........-...
2,dd-a',. e........ ....................�.���.
Integrator: ........ [�pl.
Operator Certification Number: ..... f 7qB z- --,--„
.............(0.-.7�.... .1.,02 ......... ..r..................................... .....................................................................
Latitude �' �`�� Longitude'
Design Current.''-_- LL n Design _ Current -- Design Current
_
ESvine Poultry- - Ca acity. utatorr Cattle-
Capacity Po Mahon acity Po ulation iii
Wean to Feeder ❑ Layer ❑ Dairy
❑ Feeder to Finish ❑ Non -Layer ❑ Non -Dairy
❑ Farrow to Wean
❑ Farrow to Feeder ❑ Other - -
❑ Farrow to Finish TbW Design Capadty
❑ Gilts _
❑Boars Tot,
SS
Nuof Lagoons ❑Subsurface Drains Present ❑ Lagoon Area ❑Spray Field Area
,HoIdingmber Ponds'/ Solid Traps E_ No Liquid Waste Management System
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: [I 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/rnin'?
d. Does discharge bypass a lagoon system? (If yes, notify DWQ)
2. Is there evidence of past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge?
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5
Identifier: !
Freeboard (inches): 7j._ . .............................................................. ............................
5. Are there any immediate threats to the integrity of any of the structures observed? (iel trees, severe erosion,
seepage, etc.)
3/23/99
❑ Yes )(No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes XNo
❑ Yes No
❑ Yes No
Structure 6
❑ Yes ko
Continued on back

Facility Number:- — Date of Lnspection
- 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?
1 L Is there evidence of over application? 0 Excessive Ponding ❑ PAN
12. Crop type
L•
IUDG�
r
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)?
14. a) Does the facility lack adequate acreage for land application?
b) Does the facility need a wettable acre determination?
c) This facility is pended for a wettable acre determination?
15. Does the receiving crop need improvement?
16. Is there a lack of adequate waste application equipment?
Required Records & Documents
17. Fail to have Certificate of Coverage & General Permit readily available?
18. Does the facility fail to have all components of the Certified Animal Waste Management Plan readily available?
(ie/ WUP, checklists, design, maps, etc.)
19. Does record keeping need improvement? (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?
�i'6 i'i.4 ioiis:o:r• deficiencies were noted dtrrift this:vis.
it: • :Y:oir WHI-f. eeeiye �i6 further -
cori-esnorideitce: about this visit.
❑ Yes kT No
❑ Yes No
❑ Yes No
❑ Yes Pd No
❑ Yes A No
❑ Yes CR No
❑ Yes kNo
❑ Yes XNo
❑ Yes No
❑ Yes i] No
❑ Yes V N6
❑ Yes Ir No
❑ Yes` P,No
❑ Yes KNo
❑ Yes fan
No
❑ Yes No
❑ Yes No
❑ Yes M No
❑ Yes No
❑ Yes No
❑ Yes No
99

Facility Number: /'� J —�� [late of ifispection
Odor Issues
26.
Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below
❑ Yes
JVNo
liquid level of lagoon or storage pond with no agitation?
27.
Are there any dead animals not disposed of properly within 24 hours?
❑ Yes
M-No
28.
Is there any evidence of wind drift during land application? (i.e. residue on neighboring vegetation, asphalt,
❑ Yes
MNo
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
LVr 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?
KYes
❑ No
3/23/99

Y;
❑ Division of Soil and Water Conservation ❑ Other Agency
® Division of Water Quality
19 Routine 0 Complaint 0 Follow-up or DWQ inspection 0 Follow-up of DSWC review 0 Other
Date of Inspection ] 2�
Facility Number ( Time of Inspection 24 hr. (hh:mm)
0 Registered IRCertified [3 Applied for Permit JBPermitted 113 Not Operational i Date Last Operated: ...
Fares Name:..----.-- ...' .... ..... Y .LA r.......: .... County DV jL�:...............
Owner Name ................. j .'�`. .ii S�.if4x...... . Phone No: CR,* ].-z 's-.. Q
Facility Contact:................................................................... ....... Title:..................... .. Phone No:
ID N
Mailing Address:..........1`b...................... .... ....A!t6u....
.. f
.........................---
.......
Onsite Representative: .............. Ii�.......... :......... ......................... Integrator: ........... A
Certfied Operator:...............C................. ....Lbc.:..........---.....................---.Operator Certification umber....J. 19Z..............------...
Location of Farm:
.....................oin......... ...... A a.......ta....................AA.2_3.. ..Q:....(nA1.eG.....i4kS.......ef------ ..ira... A.k..r.................................................................... �
................................................... .............. .... ...
Latitude • ©6 ®" Longitude �l`1 * ►{'l ` "
General
1.
Are there any buffers that need maintenance/improvement?
❑ Yes
0 No
2.
Is any discharge observed from any part of the operation?
❑ Yes
P No
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a. If discharge is observed, was the conveyance man-made?
❑ Yes
[P 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?
Kdj
d. Does discharge bypass a lagoon system'? (If yes, notify DWQ)
❑ Yes
No
3.
Is there evidence of past discharge from any part of the operation?
❑ Yes
[)3 No
4.
Were there any adverse impacts to the waters of the State other than from a discharge?
❑ Yes
[� No
5.
Does any part of the waste management system (other than lagoons/holding ponds) require
❑ Yes
No
. maintenance/improvement?
6.
Is facility not in compliance with any applicable setback criteria in effect at the time of design?
❑ Yes
No
7.
Did the facility fail to have a certified operator in responsible charge?
❑ Yes
O No
7/25/97

Facility Number: -31 — 4
8. Are there lagoons or storage ponds on site which need to be properly closed?
Structures (Lagoons,1Ioldine Ponds._Flush Pits, etc.)
9. Is storage capacity (freeboard plus storm storage) less than adequate?
❑ Yes MNo
❑ Yes No
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Freeboard(tt)..............I................... ....................................
10. Is seepage observed from any of the structures? ❑ Yes No
11. Is erosion, or any other threats to the integrity of any of the structures observed? ❑ Yes No
12. Do any of the structures need maintenance/improvement? 19 Yes ❑ No
(If any of questions 9-12 was answered yes, and the situation poses
an immediate public health or environmental threat, notify DWQ)
13. Do any of the structures lack adequate minimum or maximum liquid level markers? []Yes No
Waste Application
14. Is there physical evidence of over application? ❑ Yes No
(If in excess of WMP, or runoff `entering waters of the State, notify DWQ)
15. Crop type ...bujn a) . .........................1 ?1 R..... 1.1.V !-U.................
16. Do the receiving crops differ with those designated in the Animal Waste Management Plan (AWMP)? ❑ Yes ® No
17. Does the facility have a lack of adequate acreage for land application? ❑ Yes f9 No
18. Does the receiving crop need improvement? ❑ Yes JB No
19. Is there a lack of available waste application equipment? ❑ Yes R] No
20. Does facility require a follow-up visit by same agency? ❑ Yes ® No
21.
Did Reviewer/Inspector fail to discuss review/inspection with on -site representative?
❑ Yes
No
22.
Does record keeping need improvement?
Yes
❑ No
For Certified or Permitted Facilities Only
23.
Does the facility fail to have a copy of the Animal Waste Management Plan readily available?
❑ Yes
No
24.
Were any additional problems noted which cause noncompliance of the Certified AWMP?
❑ Yes
No
25.
Were any additional problems noted which cause noncompliance of the Permit?
❑ Yes
No
0U No:violkions-or deficiencies e're,itoted-during this:visit.- You:will Teceive-no' Airther,
:-:-correspQndenceatiouit:his:visit.-::-.:-:•.�:•:••:•:::�: :•:•:•:..�::�: :-: . : .•:-: :-. _ .:-
lir, Co�-�►we, loc.*­t apt oi, (optiti d1 , w4l.
zz. 1,4b # I i, 4t, ; .40_ den,,, ccy4pJ Sw i%,Lwwd
"4. s-M Por G COiy df COC
7125197
Reviewer/Inspector Name
Reviewer/Inspector Signature: lz„` /�� Date: