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a t � Tuiriber_.� 7/ 7t;4 " °y" Q Division of Soil9and'Water_Conseirvation'-. - '<r"r'
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Type of Visit: 0 Compliance Inspection Operation Review tructure 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: r Departure Time: L7 County: Region:
Farm Name: "t5i" Owner Email:
Owner Name: Phone:
Mailing Address:
Physical Address:
Facility Contact: n Title: Phone:
Onsite Representative: (J �n ui`rh�,,,, I jwx o rii Integrator•
Certified Operator: Certification Number:
Back-up Operator: Certification Number:
Location of Farm: Latitude: Longitude:
besi iN r
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Finish La er = DairyCow
"� Feeder ' Non-La er _' Da' Calfo Finish8 Da' Heifer
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Farrow to Wean a '"`; =aF°`Deli n'¢eCurrerif. D Cow
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Farrow to Feeder
I) ;`Foul_ dsCa'aei' a po '` _- Non-Dai
=' Farrow to Finish ILayers Beef Stocker
Gilts Non-La ers Beef Feeder
Boars jPullets Beef Brood Cow
Turkeys --
`_ 4
�Ofher Turkey Pouets
Other
Other
Discharges and Stream Impacts
1.Is any discharge observed from any part of the operation? ❑ Yes No ❑ NA ❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance man-made? ❑ Yes ❑ No ❑ NA ❑ NE
b. Did the discharge reach waters of the State?(If yes,notify DWR) ❑ Yes ❑ No ❑ NA ❑ NE
c. What is the estimated volume that reached waters of the State(gallons)?
d. Does the discharge bypass the waste management system?(If yes,notify DWR) ❑ Yes ❑ No ❑ NA ❑ NE
2.Is there evidence of a past discharge from any part of the operation? ❑ Yes �j No ❑ NA ❑ NE
3.Were there any observable adverse impacts or potential adverse impacts to the waters ❑ Yes No ❑ NA ❑ NE
of the State other than from a discharge?
Page I of 3 21412015 Continued
Facility Number: jDate 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 777❑��� No ❑ NA ❑ NE
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: T Z
Spillway?:
Designed Freeboard(in):
Observed Freeboard(in): ` 3 3
5.Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes [�] No ❑ NA ❑ NE
(i.e.,large trees,severe erosion,seepage,etc.)
6.Are there structures on-site which are not properly addressed and/or managed through a ❑ Yes �ZrNo ❑ 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 [9 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 `7W No ❑ NA 0 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? 0 Yes ❑ No ❑ NA [V)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 ❑ No ❑ NA ® NE
18.Is there a lack of properly operating waste application equipment? ❑ Yes ❑ No ❑ NA W 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 ❑ No ❑ NA [)o NE
the appropriate box.
❑WLTP ❑Checklists ❑Design ❑Maps ❑Lease Agreements ❑Other:
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 ❑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 [�j NE
23.If selected,did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes ❑ No ❑ NA P NE
Page 2 of 3 21412015 Continued
Facifi Number: / - 744 Date of—inspection: / —7-
24.Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes ❑ No ❑ NA 0 NE
0.
25.Is the facility out of compliance with permit conditions related to sludge? If yes,check ❑ Yes ❑ No ❑ NA 5fl NE
the appropriate box(es)below.
❑Failure to complete annual sludge survey ❑Failure to develop a POA for sludge levels
❑Non-compliant sludge levels in any lagoon
List structure(s)and date of first survey indicating non-compliance:
26.Did the facility fail provide documentation of an actively certified operator in charge? ❑ Yes ❑ No ❑ NA 14 NE
27.Did'the facility fail to secure a phosphorus loss assessments(PLAT)certification? ❑ Yes ❑ No ❑ NA [)o NE
Other Issues
28.Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes [—] No ❑ NA NE
and report mortality rates that were higher than normal?
29.At the time of the inspection did the facility pose an odor or air quality concern? ❑ Yes ❑ No ❑ NA �NE
If yes,contact a regional Air Quality representative immediately.
30.Did the facility fail to notify the Regional Office of emergency situations as required by the ❑ Yes N No ❑ NA ❑ NE
permit?(i.e.,discharge,freeboard problems,over-application)
31.Do subsurface tile drains exist at the facility?If yes,check the appropriate box below. ❑ Yes ❑ No ❑ NA [ .NE
❑Application Field ❑ Lagoon/Storage Pond ❑ Other:
32.Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes ❑ No ❑ NA [ NE
33.Did the Reviewer/Inspector fail to discuss review/inspection with an on-site representative? ❑ Yes W No ❑ NA ❑ NE
34.Does the facility require a follow-up visit by the same agency? ❑ Yes EA
No ❑ NA ❑ NE
Commep4g(refer to question#f):Explli*any YES answers and/or any additional_reeommendations,or any othertomments.
Use drarvin'gs of facility;eo better explain situations(use additional°'pages as necessar),).
6F OF /V,,w
3q Id �6
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Reviewer/Inspector Name: ,' _�c� Phone: ,tll-7�
Reviewer/Inspector Signature: Date:
Page 3 of 3 21412015