820491_INSPECTIONS_20171231

NUH I H LAHULINA
Department of Environmental Qual

1 v -5 F-t6
Division of Water Resources
Facility Number 2 - ®Division of Sail and Water Conservation
QO Other Agency
type of Visit:()Compliance Inspection Operation Review 0 Structure Evaluation p Technical Assistance
Reason for Visit: Routine Q Complaint O Follow-up Q Referral Q Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: Departure Time: l +� County: 'm Region:
Farm Name: �'�,� � f* t • e G v.4,v _' Owner Email:
Owner Name: �t q'� Q� �4ry` ``Y[ �✓` Phone:
Mailing Address:
Physical Address:
Facility,Contact: 0 [t.1 t 1°-� Title:
Onsite Representative: {
Certified Operator:
Back-up Operator: +[ a t c*N
Phone:
Integrator: PVcC NO, _
Certification Number: 7 Y
Certification Number: j 7je s
Location of Farm: Latitude: Longitude:
l5ign Current
Design Current Design :, Gurren#
Ratt
Swine
Capacity Pop.
Wet Poultry
Capacity Pop. Capacity Pop.
Wean to Finish
ILayer
Dair
y Cow
Wean to Feeder
]Non -Layer
DairyCalf
Dahy Heifer
Feeder to Finish
%
i{5
Farrow to Wean
Design Current Dry Cow
Farrow to Feeder
D , P,oul "":
Ca aci P.a Non -Dairy
Farrow to Finish
Layers
Beef Stocker
Beef Feeder
Gilts
Non -Layers
Pullets
Beef Brood Cow
Turkeys
11 OlBoars
Turke Puults.
er
I
10ther
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?
❑ Yes []-N° ❑ NA ❑ NE
❑ Yes ❑ No E�J"NA ❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWR) ❑ Yes ❑ No DNA ❑ 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 0 No El"NA ❑ NE
2. Is there evidence of a past discharge from any part of the operation? ❑ Yes [ F4o ❑ NA ❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters ❑ Yes CTNo ❑ NA ❑ NE
of the State other than from a discharge?
Page 1 of 3 21412015 Continued /'

Facility Number: Date of Inspection: 7 r
{�
Waste Collection & Treatment
4. is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
[�-Ne—
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
0 No
�
❑ NE
Structure 1 Structure 2 Structure 3 Structure 4
Structure 5
Structure
6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): 1�
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
'
t❑-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
I3 "'o
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4fi were answered yes, and the situation poses an immediate public health
or environmental
threat, notify DWR
7. Do any of the structures need maintenance or improvement?
❑ Yes
©-<o
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
LJ "o
❑ NA
❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require
❑ Yes
❑ o
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
E N
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes �o ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 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): C 6 4CL4 l r
x t
13. Soil TYpe(s): / I�
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 [D-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?
❑ Yes E-No ❑ NA ❑ NE
❑ Yes [—TN ❑ NA ❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes [A-N-o ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes []-IVo ❑ 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 [lFio
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall El Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and I" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes rrNo
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 21412015 Continued

Facili Number: Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes [c-Ne- ❑ NA ❑ NE
il
25. is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes [3-N—o ❑ NA [] NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail 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 E -5-6 ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 fours 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
[TNo
❑ 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
[5-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
[3-No
❑ NA
❑ NE
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance ofthe permit or CAWMP?
❑ Yes
M—No
❑ NA
❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
[fNo
❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
El"No
❑ NA
❑ NE
Comments (refer to question-#) Explainany-YES answers and/or any additional recommendations or any oth& comments.:'
... �1 ty p ds P g r y) , ..
Ilse drarqur " of-Eacili " to better ea' lazs'itnaans use addrttonal a es as necessa
SQ r`7 3j 2.
c'_j r j k 5 (
Reviewer/Inspector Name:
Reviewer/Inspector Signatut
Page 3 of 3
Phone:
Date: -7-)' t
21412015

Type of visit: (-Compliance Inspection V Operation Review V structure Evaluation (, -I-echnical Assistance
Reason for Visit: (>R1ro_utine 0 Complaint 0 Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: M I n Arrival Time: Departure Time: rCounty: Regiot�_
Farm Name: K to "'^ Owner Email:
Owner Name:A-1 1 G[ 4-1 Phone:
Mailing Address:
Physical Address: r
Facility Contact: �[ rD.�'- Title: Phone:
t!
Onsite Representative:
Certified Operator: t,
Back-up Operator: u` CC H
4'A—.
Integrator: fr
Certification Number. n Os
Certification Number: t L U K
Location of Farm: Latitude: Longitude:
Design
Swine Capacity
e'signCurrenk'" Design Current
Current 11ILsj
Pop. WetPoultry Capacity TMPop ...:: Cattle �:"„ Capacity Pop.
a
Wean to Finish
],aver Dairy Caw
Wean to Feeder
Non -La er
Dai Calf
Feeder to Finish
= �` fi �4,. ` Dai Heifer
�r_ ;
Design�Curent Dry Caw
D P,ttilt . Ca itzl'o r Non -Dairy
Layers Beef Stocker
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Non -Layers
Beef Feeder
Boars
Other
11 Other
Pullets
Turkeys
Beef Brood Cow
Turkey Poults'
Other:
Discharses and Stream Impacts
1. Is any discharge observed from, any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
❑ Yes UA-ITo ❑ NA ❑ NE
a. Was the conveyance man-made? ❑ Yes ❑ No [ffNA ❑ NE
b. Did the discharge reach waters of the State'? (If yes, notify DWR) [:]Yes ❑ No ['TNA ❑ 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 E NA ❑ NE
2. Is there evidence of a past discharge from any part of the operation? ❑ Yes [rNo ❑ NA ❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters ❑ Yes E No ❑ NA ❑ NE
of the State other than from a discharge?
Page 1 of 3 21412015 Continued

acili Number; fl, - ITJ Date of Inspection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes C3-K55—❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No Q-MA ❑ NE
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes Gg-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 Lal�o ❑ 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
DOany of the structures need maintenance or improvement? es MS ❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit? [! Yes Ej"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 [2'1�o ❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes �No ❑ NA
❑ NE
maintenance or improvement?
11. is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes 2reNo ❑ NA
❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN M PAN > 10% or 10 lbs. ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑f Evidence ft ❑ of Wind DriApplication Outside of Approved Area
}
12. Crop Type(s): C 3 Ttuy ,'
a
13. Soil Type(s):
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes [rNo ❑ NA ❑ NVE
15. Does the receiving crop and/or land application site need improvement? [—]Yes El"'No ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable [:]Yes [B'llo [DNA ❑ 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 [�No ❑ NA ❑ NE
❑ Yes �No ❑ NA ❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available? ❑ Yes [?j"No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ' ❑ Yes [TNo [:]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 C!fNe
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Rainfall [] Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and i" Rainfall Inspections
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes ff No
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 21412015 Continued

acili Number: - Date of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
[L�'1 !�o
❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check
❑ Yes
Ug-l<
❑ NA ❑ NE
the appropriate box(es) below.
❑ Failure to complete annual sludge survey ❑ Failure to develop a POA for sludge levels
❑ Non -compliant sludge levels in any lagoon
List structure(s) and date of first survey indicating non-compliance:
26. Did the facility fail provide documentation of an actively certified operator in charge?
❑ Yes
NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification?
❑ Yes
2 No
❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Application Field ❑ Lagoon/Storage fond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes [BNo ❑ NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? ❑ Yes dNo ❑ NA ❑ NE
34. Does the facility require a follow-up visit by the same agency? ❑ Yes E2-1Vo ❑ NA ❑ NE
ry
Use (refer to
drawings facility to be eX lain sitpat ons��use addt�tranala es as necessaommt�mendations ar ary of mments.
#) P y y Y
its ca CV1_ O Lk, t �4ecrict7v-
[:]Yes �' o 0 NA ❑ NE
❑ Yes NA ❑ NE
❑ Yes ETNo ❑ NA ❑ NE
❑ Yes '["No ❑ NA ❑ NE
3,)e- s t
Reviewer/Inspector Name: Phone: —1
333
Reviewer/Inspector Signature: Date-16-F1 l
Page 3 of 3 21412015

Type of Visit: Zoutine
ante Inspection Operation Review p Structure Evaluation 0 Technical Assistance
Reason for Visit: O Complaint O Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit: Arrival Time: Departure Time: County: `L. � Region: f
Farm Name:! .0 (jkA A)" (o a--`
Owner Name: - _ —got
Mailing Address:
Physical Address:
Owner Email:
Phone:
Facility Contact: 1Dd_C'-'4 /0-• Title: Phone:
Onsite Representative: Integrator:
Certified Operator -
Back -up Operator:
Location of Farm:
Latitude:
Certification Number:
Certification Number:
Longitude:
1&7 s
17 t7 f�
Design Current
Design-` .Curren#
Design Current
Swine Capacity Pop.
:Vet Poultry Capacity ° 1'oep.
Cattle Capacity Pop.
WW
Wean to Finish
La er
D ' Cow
Wean to Feeder
Non-1 a er
D ' Calf
Feeder to Finish
_ _ y
D ' Heifer
Farrow to Wean
D . ,Moult .
Designs Current
Gat ci P,o
D Cow
Non-Dal
Farrow to Feeder
Farrow to Finish
Layers
Beef Stocker
Gilts
Non -Layers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turkeys
er
Turke Poults,k
�...;::e..u.
Other
�a�3..�916'LWdu!'n'9K
xAl ::
Other
...,,.'✓*„ i.:ti�� 7tS.C:a:iau,s-,.�
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
ff 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
[:I&A
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
[—]Yes
allo
❑ NA
❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters
❑ YesrNo
❑ NA
❑ NE
of the State other than from a discharge?
Page 1 of 3 21412014 Continued

]Futility Number: - Date of lns ectlon: 12 livitIA
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes [Z-Ko �❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No TA ❑ 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 �o
[:]Yes No
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental t
7. Do any of the structures need maintenance or improvement? ❑ Yes g "o
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes E No
(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
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
maintenance or im rovement9
❑ Yes I3 o'o
❑ Yes . No
9A ❑ NE
Y
NA ❑ NE
notify DWR
01
NA ❑ NE
I�A ❑ NE
NA ❑ NE
0)
NA ❑ NE
P
Is there evidence of incorrect land application? If yes, check the appropriate box below. [:]Yes ZNo AA
❑ 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):
y�
❑ NE
6
13. Soil Type(s):
007
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 i2 o ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable [—]Yes [; No ❑ NA ❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
L.J two
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
Oo
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
L_J 1�
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Ycs
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
[ij-5b
[DNA
❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis [] Soil Analysis
❑ Waste Transfers
❑ Weather Code
❑ Rainfall [:]Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and I" Rainfall Inspections ❑ 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
21412014 Continued

F'acili 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 to provide documentation of an actively certified operator in charge? ❑ Yes 0<0 ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes ( Na ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes To ❑ 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 duality concern? [:]Yes 5; ' o ❑ NA ❑ NE
If yes, contact a regional Air Quality representative immediately,
30. Did the facility fail to notify the Regional Office of emergency situations as required by the [] Yes Q 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
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes Q "o
33. Did the Reviewer/inspector fail to discuss review/inspection with an on -site representative? ❑ Yes 3-ITO
34. Does the facility require afollow-up visit by the same agency? ❑Yes [�'No
❑ NA ❑ NE
❑NA ❑NE
❑ NA ❑ NE
❑ NA ❑ NE
Comments (refer WL question #f):.Explain any_°-Y,ESFanswers and/or -any additional recommendations or any other comments: ,-
Use drawings of facility to better explain situations (use.,additional pages as necessary):
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: 33, 33`
Date: w
21412014

Type of Visit: &C-ompliance-Inspection % UQperation Review 0 Structure Evaluation Q Technical Assistance
Reason for Visit: & outihie '0 Complaint 0 Follow-up O Referral O Emergency O Other Q Denied Access
Date of Visit: Arrival Time: ; i u Departure Time: County: tjT�:a�� egion:
Farm Name: vlu' (C-1 Owner Email:
?�
Owner Name: �fr,6 Phone;
Mailing Address:
Physical Address:
Facility Contact:
b t^ Title: Phone:
Onsite Representative: r S , Integrator: B4!!�
�
Certified Operator: 4Uf e Lx' �o-" Certilleation Number: z.�M
l
Back-up Operator: Certification Number:
Location of Farm}::
t 7, CL4 mv
Wean to Finish
Wean to Feeder
Feeder to Finish
b
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Roars
Other
Latitude:
Design C
Wet Poultry Capacity
Layer
Non -Layer
Design C
D , P,oWtr. t;a aci
Layers
Non -Layers
Pullets
Turkeys
Turkey Poults
,0
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 ( allonsW
Longitude:
y Cow
y Calf
Cow
Beef Feeder
Beef Brood Cow
❑ Yes ❑ NA ❑ NE
[:]Yes [:]No NE
[:]Yes [:]No A ❑ NE
- g
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 10 ❑ NA ❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters [:]Yes E],Wo ❑ NA ❑ NE
of the State other than from a discharge?
Page I of 3
21412014 Continued

acili Number: - Date of Ins ection: , -
Wast&Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
®-Kcr­ ❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No NE
Structure I Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier:
Spillway?:
i
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
[D-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
[�"1 oC o [D NA
E] NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental
threat, notify DWR
7. Do any of the structures need maintenance or improvement?
❑ Yes
O_Ne-- ❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
NA
❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require
❑ Yes
4Ej-TT5❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
❑"lqo ❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes [2 "" ❑ 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): k3 e' r,
13. Soil Type(s): /VO C2 O
_
14_ Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
<o
❑ NA
❑ NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
[Er No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
E3<o
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
ETNo
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
ETNo
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
[3'No
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
E:�3do
❑ 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 [3"'No ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rainfall Inspections ❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge? ❑ Yes ❑ NA ❑ NE
23. if selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes g �No ❑ NA ❑ NE
Page 2 of 3 21412014 Continued

Facility Number: - Date of Ins ection:
24. Did ibe facility fail to calibrate waste application equipment as required by the permit? ❑ Yes Ea-hl�o ^❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes 0`1"0 ❑ 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(&) and date of fast survey indicating non-compliance:
26. Did the facility fail to provide documentation of an actively certified operator in charge? [—]Yes o ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes L3"ko ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below
❑ Application Field 0 Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CA WMP?
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
34. Does the facility require a follow-up visit by the same agency?
Reviewer/Inspector Name;
❑ Yes [:]�<o ❑ NA ❑ NE
❑ Yes E24o ❑ NA ❑ NE
[:]Yes ["No ❑ NA ❑ NE
❑ Yes 4.d "o ❑ NA ❑ NE
❑ Yes Yes ��.o
No
❑ Yes 1�1 0
❑NA ❑NE
❑NA ❑NE
❑ NA ❑ N1C;
Reviewer/Inspector Signature:
Page 3 of 3
21412014

Type of Visit: ��tp ' ce Inspection O Operation Review O Structure Evaluation O Technical Assistance I
Reason for Visit: outine O Complaint O Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit: arrival Time: Departure Time: County_25
Farm Name: d �'�1 Owner Email: — —/�—
Owner Name: t iKk Wi, Phone:
Mailing Address:
Physical Address:
Facility Contact: D,,
Onsite Representative: l l f
Certified Operator: 44tt*ff
Back-up Operator:
Location of Farm:
Title:
Latitude:
Region,7-PCID
Phone:
Integrator: � g $ Z I Z
-
Certification Number: `C
Certification Number:
Longitude:
Design @nrrent�„ s Design Current Design Gttrrent
Swine Capacity Ptop ,Wet Poulti-� Capactty p. rattle Capacity Pop.
Wean to Finish IMa Dairy Cow
Wean to Feeder Non -Layer Dairy Calf
Feeder to Finish° , = Dairy Heifer
Farrow to Wean �.;: , Desig�Current Cow
Farrow to Feeder _ D�yPoun Ca act �Po Non-Dan
Farrow to Finish La ers I Beef Stocker
Gilts Non -Layers Beef Feeder
Boars Pallets Beef Brood Cow
4.: Turke s
Other —.Turkex Poults
Other Other
Discharges and Stream Impacts
1. is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other_
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
❑ Yes [3,.X�D NA ❑ NE
❑ Yes [:]No
❑ Yes ❑ No
❑ NE
❑- ❑ NE
❑ Yes ❑ No ga "A ❑ NE
❑ Yes 1.3T1"" ❑ NA ❑ NE
[:]Yes t —<o ❑ NA ❑ NE
Page I of 3 21412011 Continued

Facili Number: - Date of inspection r
Waste'tollection & Treatment ��
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes �Iro ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No �"" ❑ NE
Structure I Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): 45 Z
5. Are there any immediate threats to the integrity of any of the structures observed?
[—]Yes
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
Io
❑ 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
ED'11o'
❑ NA
❑ NE
8. Do any of the structures lack adequate markers as required by the permit?
❑ Yes
L:[.icr'
❑ 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
Fj"o
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
No
❑ NA
❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below.
❑ Yes
[j/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 Cr p Window ❑ Evidence of Wind Drri�iftii ❑ Application Outside of Approved Area
12. Crop Type(s):
13. Soil Type(s): C)
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
to
❑ NA
❑ WE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
CD<o
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
&<O
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
�o
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
No
❑ NA
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
Ea o
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? if yes, check
❑ Yes
F3<o
❑ NA
❑ NE
the appropriate box.
❑ WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements
❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
E2rNo
[] NA
❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis
❑ Waste Transfers
❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and 1" Rainfall Inspections ❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge?
[::]Yes
�o
❑ NA
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
F2rN.
❑ NA
❑ NE
Page 2 of 3 21412011 Continued

Facility Number: - ' Date of Ins ection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes t!d l"' ❑ NA ❑ NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check ❑ Yes ®4o ❑ 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 13<0 ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? ❑ Yes [DA6 ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
24. 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:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
34. Does the facility require a follow-up visit by the same agency?
[—]Yes [2- No ❑ NA ❑ NE
❑ Yes do ❑ NA ❑ NE
❑ Yes �No ❑ NA ❑ NE
[:]Yes
[3 o
❑ NA
❑ NE
[:]Yes
[3No
❑ NA
❑ NE
❑ Yes
<o
❑ NA
❑ NE
[:]Yes
CTo
❑ NA
❑ NE
Reviewer/Inspector Name: / h Phone: 1 )- 1-a
-3 -My
t � [
Reviewer/Inspector Signature: Date:
Page 3 of 3 21412011

s-ion of Water Quality
Facility Number - a Division of Soil and Water Conservation
Other Agency
Type of Visit: Com ante Inspection Operation Review Q Structure Evaluation O Technical Assistance
Reason for Visit: &Routine Q Complaint O Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit: rrival Time:4 Departure Time: G 0 County RegionFI
Farm Name: lJ ,r— Owner Email:
Owner Name: t 00"" Phone:
Mailing Address:
Physical Address:
Facility Contact: �%� Title: Phone:
Onsite Representative: integrator:
Certified Operator: Li Certification Number: 1$�
Back-up Operator: : L Certification Number: f,7(r7 \
Location of Farm:
Latitude:
Longitude:
Design Current Design Current
Design Current
Swine Capacity Pop. Wet Aoultry Capacity Pop.
Cattle Capacity Pop.
Wean to Finish La er
Dai Cow
Wean to Feeder
Non -La er
Dai Calf
Feeder to Finish
Dai Heifer
Farrow to Wean
Design Current
Cow
Farrow to Feeder
D . P,oultry Ca aci 1?0 .
Non -Dairy
Farrow to Finish
Gilts
Layers
Beef Stocker
Non -Layers
Beef Feeder
Boars
Pullets
Beef Broad Cow
Turkeys
Other Turkey Poults
Other Other
Discharges and Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
ETNo
❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other:
a. Was the conveyance than -made?
❑ Yes
[] No
[2�M
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
❑ Yes
[] No
[] NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does the discharge bypass the waste management system? (If yes, notify DWQ)
❑ Yes
❑ No
B<A
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
[3 Q
❑ NA
❑ NE
3. Were there any observable adverse impacts or potential adverse impacts to the waters
❑ Yes
[:4
❑ NA
❑ NE
of the State other than from a discharge?
Page 1 of 3 21412011 Continued

ti
Va
Facility Number: U VNV tj Date of Inspection:
Waste Collection & Treatment �,��
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes 23,1 o ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? [:]Yes [—]No ❑ NA ❑ NE
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
c
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes [ -moo ❑ 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 L.J o ❑ 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 No ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? ❑ Yes [6'5o ❑ 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 L3<o ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes [D�o ❑ NA ❑ NE
maintenance or improvement?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes �p ❑ 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): 22PoLr�U^r_' _ 56 t>
13. Soil Type(s): AI d — t� 0
14. Do the receiving crops differ from those designated in the CA WMP? ❑ Yes PTNo ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes Et -No ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
Eq o
❑ 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
❑ NE
Required Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
[Z],l�o
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? if yes, check
❑ Yes
21No
❑ NA
❑ NE
the appropriate box.
[3WUP ❑Checklists ❑ Design ❑ Maps [:]Lease Agreements
❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below.
[] Yes
I a1'vo
❑ NA
❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis
❑ Waste Transfers
❑ Weather Code
❑ Rainfall ❑ Stocking ❑ Crop Yield Ell 20 Minute Inspections ❑ Monthly and I" Rainfall Inspections
❑ Sludge Survey
22. Did the facility fail to install and maintain a rain gauge?
❑ Yes
[ZJ o
❑ NA
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
Io
❑ NA
❑ NE
Page 2 of 3
21412011 Continued

Facility Number: - Date of Insection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? Yes Ef-No NA NE
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check Yes [3-10 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 L'J ""' D NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? D Yes [Rlqo— D NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air quality concern?
If yes, contact a regional Air Quality representative immediately.
30. Did the facility fail to notify the Regional Office of emergency situations as required by the
permit? (i.e., discharge, freeboard problems, over -application)
31. Do subsurface tile drains exist at the facility? If yes, check the appropriate box below.
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
Yes [t].K55 NA NE
Yes [D No ❑ NA [] NE
Yes ©Ko ❑ NA ❑ NE
Yes t.'h"lo NA D NE
32_ Were any additional problems noted which cause non-compliance of the permit or CAWMP? D Yes Ca>o D NA ❑ NE
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative? [—]Yes [.-}-iVo NA NE
34. Does the facility require a follow-up visit by the same agency? 0 Yes �o ❑ NA ❑ NE
Use tifawiin s (refer to question #) ExpWn any answers and/or any additional recommendations or any other emments
Comments {re
g- "of=facility to better re -
se (use additional pages as necessary). r
C4"bv-4�'" — fj_-[6-t[
C(�e S�Vuel tt- 16 - cq_ o- 3.-7
Reviewer/Inspector Name:
Reviewer/Inspcetor Signature:
Page 3 of 3
Phonec: U0
Date: U
21417011

L4q
Type of Visit: Q Compliance Inspection () Operation Review U Structure Evaluation U Technical Assistance I
Reason for Visit: Q/Routine 0 Complaint O Follow-up 0 Referral 0 Emergency 0 Other 0 Denied Access
Date of Visit: Arrival Time: Aa'1 Departure Time: pOpvv p, County:
Farm Name: i A AJ19 fU A Owner Email:
Owner Name:r,rr{L�,n 'n, NA�lIU(� Phone:
Mailing Address:
Region: r)b
Physical Address:
Facility Contact: of) -" b Kg-(IG 2 Title: Phone: Onsite Representative: N\ q FJ NA./ 10A �! Integrator: t5lAaE
Certified Operator: z� P y �p.f,� Certification Number:
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
Design Current
Design
Current
Design Current
wine Capacity Pop.
Wet Po�ltr;
La er
Capacity
Pop.
Cattle Capacity Pop.
DairyCow
ean to Finish
ean to Feeder
Non -La er
DaCaeeder
Da' Heifer
rFarrow
to Finish
`!3
to Wean
Design
Current
D Cow
arrow to Feeder
D . P.ault ,
La ers
Non -Layers
Pullets
Ca aci
P,o
Non -Da'
Beef Stocker
Beef Feeder
Beef Brood Cow
arrow to Finish
ilts
Boars
_.
Turkeys
,
urke Puults
=--eerr--
Other
Discharges and Stream Impacts
1. is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other.
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
❑ Yes F;rNo ❑ NA ❑ NE
❑ Yes
No
❑ NA
❑ NE
[] Yes
No
❑ NA
❑ NE
d. Does the discharge bypass the waste management system? (If yes, notify DWQ) [:]Yes [] No ❑ NA ❑ NE
2. Is there evidence of a past discharge from any part of the operation? ❑ Yes [gNo ❑ 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 21412011 Continued

[Facility Number: 'A - ySl Date of Inspection: ap
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes ❑ No ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structure I Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in): 19
Observed Freeboard (in): *IA
—
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes [RfNo ❑ NA ❑ NE
(i.e., large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a ❑ Yes ❑Ao ❑ 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 Eg No ❑ NA ❑ NE
8. Do any of the structures lack adequate markers as required by the permit? [:]Yes [2'No ❑ NA ❑ NE
(not applicable to roofed pits, dry stacks, and/or wet stacks)
9. Does any part of the waste management system other than the waste structures require (:]Yes �No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ❑ Yes [2No ❑ NA ❑ NE
maintenance or improvement?
I I. 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 WindDrift ❑ Application Outside of Approved Area
12. Crop Type(s): � r..P,M'j oa4 -G o. , £ o HbtJ 4JA
13. Soil Type(s): NA --& / &0/4
14. Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
52'-No
❑ NA
[] NE
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
[eNo
[] NA
❑ NE ;
16. Did the facility fail to secure and/or operate per the irrigation design or wettable
❑ Yes
[SY�4o
❑ NA
❑ NE
acres determination?
17. Does the facility lack adequate acreage for land application?
❑ Yes
[v"No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
E21/No
❑ NA
❑ NE
Re aired Records & Documents
19. Did the facility fail to have the Certificate of Coverage & Permit readily available?
❑ Yes
QNo
❑ NA
❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check
❑ Yes
["Io
❑ NA
❑ NE
the appropriate box.
❑WUP ❑Checklists ❑ Design ❑ Maps ❑ Lease Agreements ❑Other:
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes []"No
❑ 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 No
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment? ❑ Yes No
[DNA ❑ NE
❑ Weather Code
❑ Sludge Survey
❑ NA ❑ NE
❑ NA ❑ NE
Page 2 of 3 21412011 Continued

w
Facili Number: jDate of Inspection:
24. Did the facility fail to calibrate waste application equipment as required by the permit? ❑ Yes [3"No
25. Is the facility out of compliance with permit conditions related to sludge? If yes, check []Yes E(No
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 Q�No
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? [—]Yes ❑ No
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document
[:]Yes
ff No
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
gNo
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
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
�lo
❑ Application Field ❑ Lagoon/Storage Pond ❑ Other:
32. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
[3"ONo
33. Did the Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
LF' No
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
[a'No
ACV1CWC17111spCl:for 1Vame:
❑ NA [] NE
❑NA ❑NE
❑NA ❑NE
WNA ❑ NE
❑NA ❑NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
❑NA ❑NE
Reviewer/Inspector Signature:
Page 3 of 3
Date:
21412011

Type of Visit: Qtomoance Inspection 0 Operation Review p Structure Evaluation O Technical Assistance
Reason for Visit: e Routine O Complaint O Follow-up O Referral O Emergency O Other O Denied Access
Date of Visit: Arrival Time: '. p Departure Time:1 ? `D County: +—Region:
Farm Name: _ Owner Email:
Owner name: '� pn,�Gz c_ N�D / _ Phone:
Mailing Address:
Physical Address:
Facility Contact: f� `.r3{ �Qcy�� Title: 61&J/>j_._ � Phone:
Onsite Representative: integrator:/�S �•��
Certified Operator: Certification Number:
Back-up Operator: Certification Number:
Location of Farm:
Latitude:
Longitude:
Design Current
Design Curt-ent
Design Current
Swine
Capacity Pop.
Wek Poultry Capacity° 'Pop.
Cattle
Capacity Pop.
Wean to Finish
La er
Dai Cow
Wean to Feeder
Non -La er
Dairy Calf
Feeder to Finish
7127-
Dairy Heifer
Farrow to Wean
Design
Current
Dry Cow
Farrow to Feeder
044aciP.o
Non -Dairy
Farrow to Finish
La ers
Beef Stocker
Gilts
Non -La ers
Beef Feeder
Boars
Pullets
Beef Brood Cow
Turkeys
Other . . . . . . . ......
�Turkey Poults
Other
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 DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
❑ Yes [KNo ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
DNA
❑ NE
d. Does the discharge bypass the waste management system? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any observable adverse impacts or potential adverse impacts to the waters
of the State other than from a discharge?
❑ Yes ❑ No
[-]Yes No
❑ Yes] No
[a NA ❑ NE
❑ NA ❑ NE
❑ NA ❑ NE
Page 1 of 3 21412011 Continued

Facility Number: jDate of Ins ection:
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
® No
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No
❑ NA
❑ NE
Structure 1 Structure 2 Structure 3 Structure 4
Structure 5
Structure 6
Identifier -
Spillway?:
Designed Freeboard (in):�2
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
No
❑ NA
❑ NE
waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat,
notify DWQ
7. Do any of the structures need maintenance or improvement?
❑ Yes
M 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?
11. Is there evidence of incorrect land application? If yes, check the appropriate box below. ❑ Yes M 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): _"D f �( p
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes allo ❑ 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?
[:)Yes 0 No ❑ NA ❑ NE
❑ Yes 2R No ❑ NA ❑ NE
Reauired 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 0 No ❑ NA [] NE
the appropriate box.
❑WUP [—]Checklists ❑ Design ❑ Maps 0 Lease Agreements ❑Other:
21. Does record keeping need improvement? if yes, check the appropriate box below. ❑ Yes Q 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 No
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 21412011 Continued

Facili Number: IDate 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 No ❑ NA ❑ NE
27. Did the facility fail to secure a phosphorus loss assessments (PLAT) certification? [:] Yes ® No ❑ NA ❑ NE
Other Issues
28. Did the facility fail to properly dispose of dead animals with 24 hours and/or document ❑ Yes No ❑ NA ❑ NE
and report mortality rates that were higher than normal?
29. At the time of the inspection did the facility pose an odor or air duality concern? ❑ Yes ® No ❑ NA ❑ NE
If yes, contact a regional Air Quality representative immediately.
34. 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 Q 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
® No
❑ NA
❑ NE
34. Does the facility require a follow-up visit by the same agency?
❑ Yes
® No
❑ NA
❑ NE
Comments (refer to question #): Explain any YE;!j�'answers and/or any additional recommendiiEtxonszortany other comtrtents.
Use draw tngs'nf.iacility to better explain situations`(u`se-additional ipakes as necessary)
Reviewer/Inspector Name:
Reviewer/Inspector Signature:
Page 3 of 3
Phone: �-
Date:
21412011

ivision of Water Quality r '�
Facility Number ` Q Division of Soil and Water Conservation
1111111111111[
('� Other Agency
Type of Visit ompliance inspection O Operation Review O Structure Evaluation O Technical Assistance
Reason for Visit autine O Complaint O Follow up O Referral O Emergency O Other ❑ Denied Access
Date of Visit: Arrival Time: . _ Departure Time: ' 3 County: Region:
Farm Name:�ffD/` /J Owner Email:
Owner Name: �s7� _ L-lJir� Phone:
Mailing Address:
Physical Address:
Facilit;
Onsite
Certifi,
Sack -up Operator -
Title: /2I.2r7-i
_ Phone No:
�` Operator Certification Number: ����
B
ack -up Certification Number:
Location of Farm: Latitude: 0 0 = . = Longitude: = ° = 4 =
ii
Design Current
Swine Capacity Population
Design Current
Wet Poult Capacity Population
Design Current
Cattle Capacity Population
❑ Wean to Finish
❑ Layer _
❑ Dairy Cow
❑ Wean to Feeder
I IEJ
Non -Layer
I I
❑ Dairy Calf
U?Fecderto Finish
El
Dry Paultry
Dairy Heifer
❑ D Cow
❑ Non -Dairy
❑ Layers
❑
❑ Non -Layers
❑ Pullets
El Beef Brood Co
lumbar of Structures:
El Turke s
❑ TurkeyPoults
❑ Other
Other
❑ Other
Farrow to Wean
El Farrow to Feeder
❑ Farrow to Finish
Discharges &Stream Impacts
1.
is any discharge observed from any part of the operation?
❑Yes
9'No
❑ NA
❑ NE
Discharge originated at: ❑Structure El Application Field ❑Other
a. Was the conveyance man-made?
❑Yes
❑ No
❑ NA
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
❑Yes
❑ No
❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
❑Yes
❑ No
❑ NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
El Yes
®'1•To
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑Yes
�o
❑ NA
❑ NE
other than from a discharge?
I2/28/04
Continued

s
Facility Number: — g / Date of Inspection �O
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 I Structure 2 Structure 3 Structure 4
Structure
5
Structure 6
Identifier:
Spillway?:
Designed Freeboard (in): / �}
Observed Freeboard (in): 3
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
-
f3 No
❑ NA
❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
❑ Yes
Elmo
❑ 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?
."'es
❑ No
❑ NA
❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes ENo ❑ NA ❑ NE
(Not applicable to roofed pits, dry stacks and/or wet stacks) ,
4. Does any part of the waste management system other than the waste structures require El Yes Ll No ❑ NA ❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need ElYes LJ No ❑ NA ❑ NE
maintenance/improvement?
1 I . Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes ETNo ❑ NA ❑ NE
❑ Excessive'Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
[--]PAN ❑ PAN > 10% or ] O 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) � j_ z/fy{/
13. Soil type(s) /J
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes 9 Flo ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes RKo ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination? ❑ Yes ❑_lo ❑ NA ❑ NE
17. Does the facility lack adequate acreage for land application? ❑ Yes <o ❑ NA ❑ NE
18. is there a lack of properly operating waste application equipment? ❑ Yes Er5o ❑ NA ❑ NE
��1B1✓ (,(f�.5 C � d�rj � a n� �a�-�,5, vC rJa/�L-� � ..S �' � iU D �����5
Reviewer/Inspector Name 5 _ Phone: i} LgIZ`33p C:>
Reviewer/Inspector Signature: Date: /2 —'Ae/D
Page 2 of 3 12128104 Continued

Facility Number. — g / Date of Inspection / - 'V
Rewired Records & Documents ��/
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes ICJ No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes 81�o ❑ NA ❑ NE
the appropriate box_ ❑ VVUp ❑ Checklists ❑ Desig
n El Maps ❑Other
21.
Does record keeping need improvement? If yes, check the appropriate box below.
❑ Yes
LJ No
❑ NA
❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers
❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V
Rain Inspections El
Weather Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
E No
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
0 1Vo
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
Mo
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
B'J�o
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
BNo
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
❑'No
❑ NA
❑ NE
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP? ❑ Yes Q<o ❑ NA ❑ NE
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
Ej"�o
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30. At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
�
E 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
�TNo
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32. Did Reviewer/Inspector fail to discuss reviewlinspection with an on -site representative?
❑ Yes
0 No
❑ NA
❑ NE
33. Does facility require a follow-up visit by same agency?
❑ Yes
No
[I[I(NA
NE
12128104

Type of Visit (5Compliance Inspection Q Operation Review Q Structure Evaluation Q Technical Assistance
Reason for Visit Mine O Complaint O Follow up O Referral O Emergency O Other ❑ Denied Access
Date of Visit: '� Arrival Time: .� C� Departure Time: County: Region:)
AV
Farm Name: v e� Owner Email:
Owner Name: �8�t SD % L42,2f Phone:
Ir
Mailing Address:
Physical Address:
Facility Contact: li�— ✓` Title: (,U r Phone No:
Onsite Representative:
Certified Operator: -
Back -up Operator:
Integrator: - Zz ff %uo�
IV
Operator Certification Number:
Back-up Certification Number:
Location of Farm: Latitude: [�o =I =N Longitude: 0° ❑
Design Current
Swine Capacity Population Wet Poultry
Design Current Design Current
Capacity Population C►attle Capaei"I Population
❑ Wean to Finish
❑ Layer
❑ Dairy Cow
❑ Wean to Feeder
on -Layer
❑ Dairy Calf
Feeder to Finish
Farrow to Wean
Dry Poultry
❑ La ers
❑ Non-ers
❑ Pullets
El Turkeys
El Turkey Poults
ElOther
❑ Daia Heifer
❑ Da Cow
❑ Non -Dairy
❑ Beef Stocker
❑Beef Feeder
ElBeef Brood Co
Number o€ Structures:
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
Other
❑ Other
Discharges & Stream Impacts
1. Is any discharge observed from any part of the operation?
❑ Yes
®No
❑ NA
❑ NE
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
❑ Yes
❑ No
❑ NA
❑ NE
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
❑ Yes
❑ No
❑ NA
❑ NE
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (if yes, notify DWQ)
❑ Yes
❑ No
❑ NA
❑ NE
2. Is there evidence of a past discharge from any part of the operation?
❑ Yes
A No
❑ NA
❑ NE
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
❑ Yes
[RLNo
❑ NA
❑ NE
other than from a discharge?
12128104
Continued

-r
Facility Number: Date of Inspection
Waste Collection & Treatment
4, is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes allo ❑ NA ❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No
❑ NA
❑ NE
Structure I Structure 2 Structure 3 Structure 4
Structure
5
Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): _
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
tR No
❑ NA
❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
❑ Yes
[3 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?
IR Yes
❑ No
❑ NA
❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit?
❑ Yes
fONo
❑ 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
RZNo
❑ NA
❑ NE
maintenance or improvement?
Waste Application
10. Are there any required buffers, setbacks, or compliance alternatives that need
❑ Yes
[&No
❑ NA
❑ NE
mai ntenanceli mprovement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes !`7 '57No ❑ NA ElNE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 101bs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
12. Crop type(s) rl► �tJ�Gf I �/' �,^' 1,U
13.
Soil type(s) I 0 :S f cr-,-pA-
T
14.
Do the receiving crops differ from those designated in the CAWMP?
❑ Yes
KNo
❑ NA
❑ NE
15.
Does the receiving crop and/or land application site need improvement?
❑ Yes
RNo
❑ NA
❑ NE
16.
Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ?
❑ Yes
R No
❑ NA
❑ NE
17.
Does the facility lack adequate acreage for land application?
❑ Yes
RNo
❑ NA
❑ NE -
18.
Is there a lack of properly operating; waste application equipment?
❑ Yes
ANo
❑ NA
❑ NE
Comments{refer to question Explain an YES anssWe6ars ndoraas nmenda ionss oe ats.y
dditonal.mecessarIse drawings of facility to better explain situations {uy): ages
Re-,iewer/Inspector Name ''�_ Phone:
Reviewer/Inspector Signature: Date: �} I�

r
Facility Number: &- Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes R No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes %No ❑ NA ❑ NE
the appropriate box. ❑ WUp ❑ Checklists ❑ Design ❑Maps El Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes KNo ❑ NA ❑ NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crap Yield ❑ 120 Minute Inspections ❑ Monthly and V Rain Inspections ❑ Weather Code
22. Did the facility fail to install and maintain a rain gauge?
❑ Yes
RNo
Cl NA
❑ NE
23. If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
3-No
❑ NA
❑ NE
24. Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
NNo
❑ NA
❑ NE
25. Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
B No
❑ NA
❑ NE
26. Did the facility fail to have an actively certified operator in charge?
❑ Yes
fa No
❑ NA
❑ NE
27. Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
®-No
❑ NA
❑ NE
Other Issues
28. Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
®No
❑ NA
❑ NE
29. Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
KNo
❑ 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
RNo
❑ 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
gLNo
❑ 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
El No
❑ NA
❑ NE
33_ Does facility require a follow-up visit by same agency?
❑ Yes
RNo
❑ NA
❑ NE
r
a
fir.
12128104

Type of Visit Ptompliance Inspection O Operation Review Q Structure Evaluation Q Technical Assistance
Reason for Visit Routine Q Complaint O Follow up Q Referral O Emergency Q Other ❑ Denied Access
Date of Visit: Arrival Time: f 0 O Departure Time: (1 County: SO'� Region:
Farm Name: Owner Email:
Owner Name: Kono-le/ I`� �f Phone:
Mailing Address:
Physical Address:
Facility Contact: m.i"d /`-' �� `� `— Title: Phone No:
Onsite Representative: G 8� Integrator:JIV
Certified Operator: Operator Certification Number:
Back-up Operator: Back-up Certification Number:
Location of Farm: Latitude: [= o [= . = « Longitude: [= ° =1 0 «
Design a Current
Design ' -@ rent
Design
Current
Swine
Capacity Population
Wet Poultry Capacity Pulatton
Cattle Capacity
Population
Finish
❑ La er
❑ Dai Cow
:E1 Ento
n to Feeder
❑ Non -Layer
❑ DairyCalf
Feeder to Finish
Sr
❑ DairyHeifer
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
sY.e.
Dry Poultry - _. _
�``
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ D Cow
❑Non -Dairy
❑ Beef Stocker
❑Beef Feeder
❑ Beef Brood Co
Other
❑ Other
❑ Turkey Poults
❑ Other
Number of Structures: ID
Discharges & Stream Impacts
1. is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure ❑ Application Field ❑ Other
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
2. is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
Page I of 3
❑ Yes Lallo ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
V+lo
❑ NA
❑ NE
❑ Yes
59 No
❑ NA
❑ NE
12/2"4 Continued

i
� �Facility Number: L' —J Date of Inspection !!1 `L-� Yl�
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
❑ Yes
0 No
❑ NA
❑ NE
a. If yes, is waste level into the structural freeboard?
❑ Yes
❑ No
❑ NA
❑ NE
Structure I Structure 2 Structure 3 Structure 4
Structure
5
Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed?
❑ Yes
MNo
❑ NA
❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed
❑ Yes
RNo
❑ 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?
aYes
❑ No
❑ NA
❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes ® No ❑ NA ❑ NE
(Not applicable to roofed pits, dry stacks and/or wet stacks)
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 JRNo ❑ NA ❑ NE
maintenance/improvement?
1 1. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes ;9No ❑ 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 /❑l /Application Outside of Area
12. Crop type(s) Zcz" I J`1L'd W i w✓ r� 140111�j
13. Soil type(s) U4 Z a rt
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes allo ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes
0 No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?[] Yes
4 No
❑ 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
51No
❑ NA
❑ NE
Reviewer/Inspector Name
Reviewer/Inspector Signature:
Page 2 of 3
Phone:
Date:
37r33oo
12128104
Continued

i Facility Number: Date of inspection[��
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes ONo ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes ® No ❑ NA ❑ NE
the appropriate box. ❑ WUP ❑ Checklists ❑ Desig
n ❑ Maps ❑ Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes B 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
W No
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
® No
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
4 No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
19 No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
K No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
MNo
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
allo
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
JN No
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30.
At the time of the inspection did the facility pose an odor or air quality concem?
❑ Yes
® No
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
31.
Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
0 No
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
A� No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
iRNo
❑ NA
❑ NE
r
Additioaal Comments and/or Draystngs;_ _:
Page 3 of 3 12128104
Page 3 of 3 12128104

ivision of Water Quality
Facility Number ' L' l O Division of Soil and Water Conservation —�c� —a/
O Other Agency
Type of Visit �tttpliance Inspection 0 Operation Review O Structure Evaluation 0 Technical Assistance
Reason for Visit a Routine a Complaint Q Follow up 0 Referral 0 Emergency Q Other ❑ Denied Access
Date of Visit: Arrival Time: ; "� Departure Time: County: Region:Q
Farm Name: A6vla% Owner Email: 10,
Owner Name: __gel � _ A4 _ Phone:
Mailing Address:
Physical Address:
Facility Contact: �� v Title: Phone No:
Onsite Representative: Integrator: Certified Operator: Operator: 41. Operator Certification Number:
Back-up Operator: Back-up Certification Number:
del
Location of Farm: Latitude: 0 e 1:1 ` Longitude: =1 ° 0 ` El"
Swine
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Farrow to Finish
Gilts
Boars
Other
❑ Other
Design Current Design Current
Capacity Population Wet Poultry Capacity Population
❑ Layer
❑ Non -La et
Dry Poultry
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ Turkey Pou Its
❑ 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?
b. Did the discharge reach waters of the State? (If yes, notify DWQ)
Design Current
Cattle Capacity Population
❑ Dairy Cow
❑ Dairy Calf
❑ Dairy Heifea
❑ Dry Cow
❑ Non-DaiEy
❑ Beef Stocket
❑ Beef Feeder
❑ Beef Brood Cowt
c. What is the estimated volume that reached waters of the State (gallons)?
Number of Structures:
d. Does discharge bypass the waste management system? (If yes, notify DWQ)
, ­_. z-
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge?
❑ Yes �& No ❑ NA ❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ Yes
❑ No
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
❑ No
❑ Yes
0 No
❑ NA
❑ NE
❑ Yes EN No ❑ NA ❑ NE
12128104 Continued

I
Facility Number: — Date of Inspection �7
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Structure I Structure 2 Structure 3 Structure 4
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in): 7,9
❑ Yes JZ No ❑ NA ❑ NE
❑ Yes ❑ No ❑ NA ❑ NE
Structure 5 Structure 6
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes
10 No
❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes
R 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
12 No
❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes
ER 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/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes
C9 No
❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or 10 lbs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
12. Crop type(s)
13_ Soil type(s)
14. Do the receiving crops differ from those designated in the CAW MP?
19 Yes
❑ No
❑ NA
❑ ME
15. Does the receiving crop and/or land application site need improvement?
❑ Yes
® No
❑ NA
❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination?[] Yes
[&No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application?
❑ Yes
® No
❑ NA
❑ NE
18. Is there a lack of properly operating waste application equipment?
❑ Yes
DqNo
❑ NA
❑ NE
Comments (refer to question ft Explain any YES answers and/or any recommendations or any other comments.
Use drawings of facility to better explain situations. (use additional pages as necessary):
/ +t/Z
.r
Reviewer/Inspector Name Phone:
Reviewer/Inspector Signature: Date: 1Oc72
12128104 Continued

Facility Number: Date of Inspection
' Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes JM No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes P4 No ❑ NA ❑ NE
the appropiate box.
❑ WUP El Checklists ❑Design El Maps ❑Other
21. Does record keeping need improvement? If yes, check the appropriate box below. Yes ❑ No ❑ NA ❑ NE
9 Waste Application ❑ Weekly Freeboard ❑ Waste Analysis o Soil Analysis ❑ Waste Transfers [:]Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and V Rain Inspections ❑ Weather Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
JK No
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
$0 No
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
W No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
R No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
JR No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
iS No
❑ NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
MNo
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
9 No
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30.
At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
ONo
❑ NA
❑ NE
If yes, contact a regional Air Quality representative immediately
31.
Did the facility fail to notify the regional office of emergency situations as required by
❑ Yes
No
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency?
❑ yes
(&No
❑ NA
❑ NE
/` n /O /'1tcc 70_; a .,. &is I <7� .;2- /'�t /rrtf .
o,n,a Mzvc
J212Voa

Type of Visit tOTompliance inspection O Operation Review Q Structure Evaluation ()Technical Assistance
Reason for Visit autine O Complaint O Follow up O Referral O Emergency O Other [I Denied Access
Date of Visit: ® Arrival Time: f , I Departure Time: ; 3 County: Region:
Farm Name: r /� f e— Owner Email:
Owner Name: r 0411T. JD �1��" _ Phone:
Mailing Address:
Physical Address:
Facility Contact: "' Title:
Onsite Representative:
Certified Operator: -
Back-up Operator:
Phone No:
Integrator:YF
Operator Certification Number:
Back-up Certification !dumber:
Location of Farm: Latitude: [= e = = u Longitude: 0 ° = I 0 "
Design Current
Design Current
Design Current
Swine Capacity Population
Wet Poultry Capacity Population
Cattle Capacity Population
❑ Wean to Finish
❑ La er
❑ Dairy Cow
❑ Wean to Feeder
I JE1 Non -Layer
El Dairy Calf
IN Feeder to Finish j
❑ Dairy Heifer
❑ Farrow to Wean
Dry Poultry
❑Dry Cow
❑ Farrow to Feeder
❑ Non -Dairy
❑ Farrow to Finish
Layers
El Beef Stocker
❑Giits
El Beef Feeder
❑ Boars
❑ Beef Brood Co
Puults
Discharaes & Stream Impacts
1. Is any discharge observed from any part of the operation?
Discharge originated at: ❑ Structure El Application Field El Other
a. Was the conveyance man-made?
b. Did the discharge reach waters of the State? (if yes, notify DWQ)
c. What is the estimated volume that reached waters of the State (gallons)?
d. Does discharge bypass the waste management system'? (If yes, notify DWQ)
2. Is there evidence of a past discharge from any part of the operation?
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State
other than from a discharge'?
Page I of 3
❑ Yes J& No ❑ NA ❑ NE
❑ Yes
KNo
❑ NA
❑ NE
❑ Yes
EqNo
❑ NA
❑ NE
❑ NA
❑ NE
❑ Yes
DkNo
❑ Yes
PkNo
❑ NA
❑ NE
❑ Yes
RNo
❑ NA
❑ NE
I2/28/04 Continued

Facility Number.
Date of Inspection (o
Waste Collection & Treatment
4, Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate?
a. If yes, is waste level into the structural freeboard?
Structure 1 Structure 2 Structure 3 Structure 4
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
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 MNo ❑ NA ❑ NE
[I Yes O.No ❑ NA ❑ NE
Structure 5 Structure 6
❑ Yes ]&No ❑ NA ❑ NE
❑ Yes allo ❑ 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 4 No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes Fs' No ❑ NA El 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 $1 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/improvement?
11. is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes KNo ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ FAN ❑ PAN > 10% or l0 Ibs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ter❑ Application Outside of Area
12. Crop type(s)
13. Soil type(s) ,/✓�a �L. /1.
14. Do the receiving crops differ from those designated in the CAWMP? ❑ Yes 00 No ❑ NA ❑ NE
15. Does the receiving crop and/or land application site need improvement? ❑ Yes RNo ❑ NA ❑ NE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination ? ❑ Yes
17. Does the facility lack adequate acreage for land application? Cl Yes
18. Is there a lack of properly operating waste application equipment?
❑ Yes
X, No ❑ NA ❑ NE
X[No ❑ NA ❑ NE
�LNo ❑ NA ❑ NE
Comments (refer to question #): Explain any YES answers and/or any recommendations 6r'any other comments
Use drawings of facility to better explain situations. (use additional pages as necessary)=
Revlewerllnspector Name-----�� Phone:/QJ!„
�7
Reviewerlinspector Signature: Date: • —�D�o
Page 2 of 3 12179104 Continued

Facility Number: $ Date of Inspection
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes KNo ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes KNo ❑ NA ❑ NE
the appropirate box.
❑ WUP El Checklists ❑Design ❑Maps ❑ Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes 92No El NA [I NE
❑ Waste Application ❑ Weekly Freeboard ❑ Waste Analysis ❑ Soil Analysis ❑ Waste Transfers ❑ Annual Certification
❑ Rainfall ❑ Stocking ❑ Crop Yield ❑ 120 Minute Inspections ❑ Monthly and I" Rain Inspections ❑ Weather Code
22.
Did the facility fail to install and maintain a rain gauge?
❑ Yes
&No
❑ NA
❑ NE
23.
If selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
WNo
X NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
�R No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
[allo
❑ NA
❑ NF
26,
Did the facility fail to have an actively certified operator in charge?
❑ Yes
No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
❑ No
0 NA
❑ NE
Other Issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
ER No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
?❑,.No
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30.
At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
P9.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
KNo
❑ NA
❑ NE
General Permit? (ic/ discharge, freeboard problems, over application)
32.
Did Reviewer/Inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
(�No
[INA
[INE
33.
Does facility require a follow-up visit by same agency?
❑ Yes
ANo
❑ NA
❑ NE
r1. y x c .t : k.o a I .,A , + s a s
A°dl�ltt(ldalrC011ltll@ntsi dliik DiflWiIIgS. ' � zt a `• s sr w r.i `r. ! x* s 6
12128104

Type of Visit 4P Compliance Inspection O Operation Review Q Structure Evaluation Q Technical Assistance
Reason for Visit 48 Routine Q Complaint Q Follow up Q Referral © Emergency O Other ❑ Denied Access
Date of Visit. L�'&/Omdnn Arrival Time: Departure Time: County: SCt7r+_p"Aj Region:
Farm Name: __1J A N a„ 110 4- _ Owner Email: -
Owner Name: P d h v 1 A D. If L w 10,0- Phnne: 91 Q- -I-(, y- j -T+0
Mailing Address:. lcsS/ (frKw..e)"P /77 a r..-L Ne
Physical Address:
Facility Contact:
Title:
Onsite Representative: Q @ K_14L_ Y • N_"St 1.-
Certified Operator: Q hdL A- e.%' _.
Back-up Operator:
Phone No:
Integrator: Pr s. 14M_ - - --
Operator Certification number: 178 'yt
Back-up Certification Number:
Location of Farm: Latitude: ❑ e =1 ❑ Longitude: [� ° ❑ ` [� "
I Swine
Wean to Finish
Wean to Feeder
Feeder to Finish
Farrow to Wean
Farrow to Feede.
Farrow to Finish
Boars
Other
❑ Other
Design Current Design Current
Capacity Population Wet .Poultry Capacity Population.
❑ Layer
J
❑ Non -Layer -` I I J
Dry Poultry
❑ Layers
❑ Non -Layers
❑ Pullets
❑ Turkeys
❑ urkey Poults
❑ Other
Discharges & Stream Impacts
I _ Is any discharge observed from any part of the operation?
Discharge originated at: ElStructure ❑ Application Field ElOther
a. Was the conveyance man-made?
Design CarrentA;,....
Cattle Capacity Population
❑ Dairy Cow
❑ Dairy Calf
❑ Dairy Heifei
❑ Dry Cow
❑ Non -Dairy
Beef Stocket
Beef Feeder
rEl
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 X No ❑ 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: .Z -- Slq Date of Inspection S / a;
Waste Collection & Treatment
4. Is storage capacity (structural plus storm storage plus heavy rainfall) less than adequate? ❑ Yes 0 No ❑ NA ❑ NE
a. If ye& is waste level into the structural freeboard? ❑ Yes ❑ No ❑ NA ❑ NE
Structure I- Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier:
Spillway?:
Designed Freeboard (in):
Observed Freeboard (in):
5. Are there any immediate threats to the integrity of any of the structures observed? ❑ Yes �fl No ❑ NA ❑ NE
(ie/ large trees, severe erosion, seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed ❑ Yes [)9 No ❑ NA ❑ NE
through a waste management or closure plan?
If any of questions 4-6 were answered yes, and the situation poses an immediate public health or environmental threat, notify DWQ
7. Do any of the structures need maintenance or improvement? ❑ Yes ® No ❑ NA ❑ NE
8. Do any of the stuctures lack adequate markers as required by the permit? ❑ Yes V1 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/improvement?
11. Is there evidence of incorrect application? If yes, check the appropriate box below. ❑ Yes ® No ❑ NA ❑ NE
❑ Excessive Ponding ❑ Hydraulic Overload ❑ Frozen Ground ❑ Heavy Metals (Cu, Zn, etc.)
❑ PAN ❑ PAN > 10% or l0 Ibs ❑ Total Phosphorus ❑ Failure to Incorporate Manure/Sludge into Bare Soil
❑ Outside of Acceptable Crop Window ❑ Evidence of Wind Drift ❑ Application Outside of Area
12. Crop type(s) o-A.w+
13. Soil type(s)p [� LN-
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
MNo
❑ NA
ElNE
16. Did the facility fail to secure and/or operate per the irrigation design or wettable acre determination,yes
M No
❑ NA
❑ NE
17. Does the facility lack adequate acreage for land application'?
❑ Yes
Q& No
❑ NA
❑ NE
18. is there a lack of properly operating waste application equipment?
❑ Yes
;4 No
❑ NA
❑ NE
Conts mme{refeflto.gtestzon #) Eitplarrr any YES'"aaswers and/or a ny re ommeodations or any other comments.
Use dra ngs of facthty to better explain sttiiab© s ,(6.k,idditionalipages*as necessary):
Reviewer/Inspector Name Phone:
ReviewerAnspector Signature: Date:
IZI-1&o4 c.anunuea

if
Facility Number: y.2 ( Date of Inspection S/It o-r
Required Records & Documents
19. Did the facility fail to have Certificate of Coverage & Permit readily available? ❑ Yes 5d No ❑ NA ❑ NE
20. Does the facility fail to have all components of the CAWMP readily available? If yes, check ❑ Yes W No ❑ NA ❑ NE
the appropirate box. ❑ WUP ❑ Checklists ❑ DesignMaps
❑ Mp ❑Other
21. Does record keeping need improvement? If yes, check the appropriate box below. ❑ Yes M 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?
❑ Yes
[0 No
❑ NA
❑ NE
23.
if selected, did the facility fail to install and maintain rainbreakers on irrigation equipment?
❑ Yes
f59 No
❑ NA
❑ NE
24.
Did the facility fail to calibrate waste application equipment as required by the permit?
❑ Yes
[4 No
❑ NA
❑ NE
25.
Did the facility fail to conduct a sludge survey as required by the permit?
❑ Yes
E,� No
❑ NA
❑ NE
26.
Did the facility fail to have an actively certified operator in charge?
❑ Yes
P No
❑ NA
❑ NE
27.
Did the facility fail to secure a phosphorus loss assessment (PLAT) certification?
❑ Yes
5fl No
❑ NA
❑ NE
Other issues
28.
Were any additional problems noted which cause non-compliance of the permit or CAWMP?
❑ Yes
[Z No
❑ NA
❑ NE
29.
Did the facility fail to properly dispose of dead animals within 24 hours and/or document
❑ Yes
141 No
❑ NA
❑ NE
and report the mortality rates that were higher than normal?
30.
At the time of the inspection did the facility pose an odor or air quality concern?
❑ Yes
® No
❑ NA
❑ 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
W No
❑ NA
❑ NE
General Permit? (ie/ discharge, freeboard problems, over application)
32.
Did Reviewer/inspector fail to discuss review/inspection with an on -site representative?
❑ Yes
(j No
❑ NA
❑ NE
33.
Does facility require a follow-up visit by same agency'?
❑ Yes
FXJ No
❑ NA
❑ NE
12128104

f
Type of Visit 0 Compliance inspection O Operation Review O Lagoon Evaluation
Reason for Visit 0 Routine O Complaint O Follow up Q Emergency Notification Q Other ❑ Denied Access
Bate Of Visit: Time: : 34 6n
Facility Number
Q Not Operational Q Below Threshold
�'ermitted ©'Certified © Conditionally Certified 13 Registered Date Last Operated or Alcove Threshold:
Farm Name: County: sus 4712
Owner Name:
Mailing Address: 1 S r�Lkr ! • +�.__ /ice i� ,� gin- �iur NL
Facility Contact: ____ . gene4k.LSO. T d-r _---- Tide:
Onsite Representative: _ _ n � _ 6*0r
Certified Operator:
Location of farm:
Phone No:
Integrator. --
Operator Certific afron Number: 1�
Ewwine ❑ Poultry ❑ Cattle ❑ Horse Latitude • " Longitude •
Swine C.M2dty Ponti#ation::
Wean to Feeder
Farrow to wean
Farrow to Feeder
Farrow to Finish
is
7 3 S
BA
Boats
'zlM Other
To#al Design
;Total SSLW_' r
Neer all .-�goanrs `; x
Discharges 8 Stream Imp
1. Is any discharge observed from any part of the operation? ❑ Yes 9NN6
Discharge originated at: ❑ Lagoon ❑ Spray Field ❑ Other
a- If discharge is observed, was the conveyance man-made? ❑ Yes 2No
b. If discharge is observed, did it reach Water of the State? (If yes, notify DWQ) ❑ Yes Jallo
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 Q-No
2. Is there evidence of past discharge from any part of the operation? ❑ Yes Q-No
3. Were there any adverse impacts or potential adverse impacts to the Waters of the State other than from a discharge? ❑ Yes 9No
Waste Collection & Treatment
4. Is storage capacity (freeboard plus storm storage) less than adequate? ❑ Spillway ❑ Yes 9•No
Structure 1 Structure 2 Structure 3 Structure 4 Structure 5 Structure 6
Identifier: I _.
Freeboard (inches): L13 �
12172103 Confined

Facility Number: 12 — yw, I Date of inspection
S. Are there any immediate threats to the integrity of any of the structures observed? (ie/ trees, severe erosion, ❑ Yes SOSo
seepage, etc.)
6. Are there structures on -site which are not properly addressed and/or managed through a waste management or ❑ Yes 210
closure plan?
(If any of questions 4-6 was answered yes, and the situation poses an
immediate public health or eaviroamental threat, notify DWQ)
7. Do any of the structures need maintenance/improvement? ❑ Yes Bl�o
8. Does any part of the waste management system other than waste structures require maintenancerimprovement? ❑ Yes [ 4o
9. Do any stuctures lack adequate, gauged markers with required maximum and minimum liquid level
❑ Yes o
elevation markings?
Waste AwDlicabon
10. Are there any buffers that need maintenancehmprovernent? ❑ Yes 21 o
11. Is there evidence of over application? If yes, check the appropriate box below. ❑ Yes ONO
❑ Excessive Ponding ❑ PAN ❑ Hydraulic Overload ❑ Frozen Ground ❑ Copper and/or Zinc
/� �GD s p /so /n.Z
12. Crop type [M/ +r�✓a%a SM.At G,ra ,-n . FPc r_ v'o , 6d *)"
13. Do the receiving crops differ with those designated in the Certified Animal Waste Management Plan (CAWMP)? ❑ Yes ❑'Wo
14. a) Does the facility lack adequate acreage for land application? ❑ Yes (] No
b) Does the facility need a wettable acre determination? ❑ Yes ❑ No
c) This facility is pended for a wettable acre determination? ❑ Yes ❑ No
15. Does the receiving crop need improvement? ❑ Yes ONO
I6. Is there a lack of adequate waste application equipment? ❑ Yes G-KO
Odor issues
17. Does the discharge pipe from the confinement building to the storage pond or lagoon fail to discharge at/or below ❑ Yes ❑ No
liquid level of lagoon or storage pond with no agitation?
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 ONo
roads, building structure, and/or public property)
20. At the time of the inspection did the facility pose an odor or air quality concern? If yes, contact a regional ❑ Yes [No
Air Quality representative immediately.
{I["CII,C.tiD IE.��a F�IB�Y�.�Y�S`ffi�9F!!S SII�fOl�y' Ot' �
3Use�drawty to ibd#str�acp�tran s�{ �P S iY) teld Copy ❑ Final Notes
_- -
p r
Pla.�, •"-, g Io i:n,t F'� ��-S ,. t �411, / �G�i►,.'.ng a sp.Ar fdr 6-ee-/s i�t ffe
SPr,�h9 C-% v, Ps1C r.
Reviewer r Name }= _ , ' -.�
r
Reviewer/Inspector Sigaatare: blozX od- Date:11
/ u
12112103 Continued

Facility Number: 82 Date of Inspection tl d
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! ; ch klis"ts, design, ;yaps, etc.}
23_ Does record keeping need improvement? If yes, check the appropriate box below.
❑AVwftzApphcadon-' ❑-%eebew+ ❑ Wnte-Analysis- [I 5eg-£�g-
[1-- r � -] 2 , SJ
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?
(iel discharge, freeboard problems, over application)
27. Did Reviewer/Impectar fail to discuss reviewfinspection 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 bore below
❑ Stocking Form ❑ Crop Yield Form ❑ Rainfall ❑ Inspection After 1" Rain
❑ 120 Minute Inspections ❑ Annual Cerdfiic:aton Form
❑ Yes 3-190
❑ Yes [[moo
❑ Yes 21go
❑ Yes B'No
❑ Yes ©-No
❑ Yes Q-Kb
❑ Yes Q.Ne-
❑ Yes 9V-O
❑ Yes CNa-
❑ Yes 04�b
0 Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
❑ Yes ❑ No
12112103

Farm Name/Owner:
Mailing
County:
Site Requires Immediate Attention: ND
Facility No. 92 - -17L91
DIVISION OF ENVIRONMENTAL MANAGEMENT
ANIMAL FEEDLOT OPERATIONS SITE VISITATION RECORD
2) A Nay to y-
.. '1 fox 30�
DATE: 3'A�3 (? , 1995
Time: 1 1 : 13
�au id Apyy i
A SQIr� b�..�~ ft1 C S3S5
Integrator:_/`'►;stcr a Faj,,cs .7&c_ Phone: l�/�1 z -�771
On Site Representative -d O !a _ Phone: /O .SCE V - Zg't0
Physical Address/Location:
Type of Operation: Swine ✓ Poultry Cattle
Design Capacity: 735, A s A Number of Animals on Site:
DEM Certification Number: ACE DEM Certification
Latitude: 35 ° 0'F ' 30 " Longitude: -l8 ° 27 ' So"
Circle Yes or No
Number: ACNEW
Can.4ra-.4 J
Does the Animal Waste Lagoon have sufficient freeboard of I Foot + 25 year 24 hour storm event
(approximately I Foot + 7 inches) es or No Actual Freeboard: 5 Ft. 0 Inches
Was any seepage observed from the la oon(s)? Yes o I�o Was any erosion observed? Yes or NN
Is adequate land available for spray? L)or No Is the cover crop adequate? (S)Dr No
Crop(s) being utilized: BerrKiA .
Does the facility meet SCS minimum setback criteria? 200 Feet from Dwellings? Yes or No
100 Feet from Wells? Yes or No
Is the animal waste stockpiled within 100 Feet of USGS Blue Line Stream? Yes or No
Is animal waste land applied or spray irrigated within 25 Feet of a USGS Map Blue Line: Yes or No
Is animal waste discharged into water of the state by man-made ditch, flushing system, or other
similar man-made devices? Yes or No If Yes, Please Explain.
Does the facility maintain adequate waste management records (volumes of manure, land applied,
spray irrigated on specific acreage with cover crop)? Yes or No
Additional Comments:_ _ Fo+- GYI�i-e-gjsreru as Kei-tk h(oN 4cu-fl- L 0ujPjzvs4%P
Re kj Rev e.1 5 _!
Inspector Name
R R—
Signature
cc: Facility Assessment Unit Use Attachments if Needed.

WORTH CAROLIM Q8PJLgT MVT OF ENVIRONMENT, BRALTS' & HATMtAL
VMSION OF F.NV7;1iONMENTu
Fayetteville Regional Office
Animal Operation Compliance inspection Form
-;,-k�:�~�<��<.��:;1�1y;f....��.�d�����p r�I:�-.r...<-•� ;'w,4��.; ��=.
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ViALfT:''�
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All questions answered negatively Will be discussed in sufficient detail in
the -Comments Section to enable the deemed Permittee to perform the appropriate
corrections:
SECTION I
Animal 92e.Latian
Horses, cattle, swine poultry, or sheep
$fox xrxr
Y I N I COMMENTS
I. Does the number and type of animal meet or exceed
the (.0217) criteria? [Cattle (100 head),
horses (75), swine (250), sheep (1,000),.and
poultry (30,000 birds with liquid waste
system)]
2. Does this facility meet criteria for
Animal Operation REGISTRATIM
3_ Are animals confined fed or maintained
in this facility for a 12-month period? -
4. Does this facility have a CERTIFIED AWIKhL
TiiASTE NL%MGEK9NT FLAW.
5. Does this facility maintain waste management
records (Volumes of manure, land applied,
spray irrigated on specific acreage With
specific cover crop)?
6. Does this facility meet the SCS minimum
setback criteria for neighboring houses,
wells, etc?

§FgTION IZI
Field —Site management
1. Is animal waste stockpiled or lagoon
construction within 100 ft. of a USGS
Map Blue Line Stream?
2. Is animal waste land applied or spray
irrigated within 25 ft. of a USGS Map
Blue Line Stream?
3. Does this facility have adequate acraage
on which to apply the waste?
4. Does the land application'site have a
cover crop in accordance'with the
CERTI ICATI©N FLAH?
5. is animal waste discharged into waters of
the state by man-made ditch, flushing system,
or other similar man-made devices?
6. Does the animal waste management at this
farm adhere to Best Management Practices
(BMP) of the approved CERTIFICATION?
7. Does animal waste lagoon have sufficient 4.1�_
freeboard? How much? (approximately -5- ?
8. is the general condition of this CAFO facility,
including management and operation,
satisfactory?
SEC' ON Sv
Coseasten t s
Qt le i �'feCi QS 0\N►ffshV _�O Dczvi d Na� l bf
CM (A Cc_r++ f-� ed

A 020M VE ST3 PLAN C3RT2FICATI0N FOR 8S25T=TG FHSDLOTS
Please retl%= the cc=pleted form to the Divisiaa of Environmental Management at
the address on the reverse side of this form.
Name of farm (Plea pri �t) : 4' V !a r
Mailing Address: f ISox 30 _-'- L./V,�_ 2 �3Fs
Phone No. 'T a - 56'-1-2') L/D ,5` 'M
County (of fares) :_ 5AMvs0n „
Farm location: Latitude and Longitude:U' E ',moo" / e �' So' (required) . Also,
please attach a copy of a county road map with location identified.
Type of operation (swine, layer, dairy, etc.) 5Nepic
.,-
Design capacity (numher of animals) 735 •F�n+s N
Average size of operation (12 month population avg.) : -73 . lP.n,S q
Average acreage needed for land application of waste (acres): 6•a
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Technical Specialist Cartification
As a technical specialist designated by the North Carolina Soil and Water
Conservation Commission pursuant to I5A NCAC 6F .0005, I certify that the
existing animal waste management system for the farm named above has an animal
waste management plan that meets the operation and maintenance standards and
specifications of the Division of Environmental Management and the USDA -Soil
Conservation Service and/or the North Carolina Soil and Water Conservation
Commission pursuant to 1SA NCAC 2H.0217 and 15A NCAC 6F .0001-.0005. The
following elements and their corresponding minimum criteria have been verified
by me or other designated technical specialists and are included in the plan as
applicable: ruinimum separations (buffers); adequate quantity and amount of land
for waste utilization (or use of third party); access or ownership of proper
waste application equipment; schedule for timing of applications; application
rates; loading rates; and the control of the discharge of pollutants from
stormwater runoff events less severe than the 25-year, 24-hour storm.
Name of Techaical specialist (Please Print)
Affiliation (Agency) : PleCTA6e FA&^S
Address: PO. 6ox µag C i + n Ta n r% L. ZS 3,ZB Phone No. 91 e ` 5 9Z- 5-7-7 r
Signatures Date:
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owner/Manager ]►Qre®eat
I (we) understand the operation and maintenance procedures established in the
approved animal waste management plan for the farm named above and will implement
these procedures. I (we) ]crow that any.expansion to the existing design capacity
of the waste treatment and storage system or construction of new facilities will
require a new certification to be submitted to the Division of Environmental
Management before the new animals are stocked. I (we) also understand that there
must be no discharge of animal waste from this system to surface waters of the
state either directly through a man-made conveyance or through runoff from a
storm event less severe than the 25-year, 24-hour storm. The approved plan will
be filed at the faros and at the office of the local Soil and Water Conservation
District. f�
Name of Lead owner (Please Print) : 1�c�»�i c� �a�.�',o� �:iA.-, I a r -
Signature: N Date: �O5y
Name of Haa*Qer, if different from owner (Please print) :
Signature: Date:
ftr.a: A change in land ownership requires notification or a new certification
(if the approved plan is changed) within 60 days of a title transfer-
DE4 USE ONLY: ACE#

State of North Carolina
Department of Environment,
Health and Natural Resources
Division ct Environmental Management
James B. Hunt, Jr., Governor
Jcnathcn B. Howes, Secretory
A. Preston Howard, Jr.. P.E., Director
INSTRUCTIONS FOR CZRTIFICATION OF APPROVED ANIMAL WASTE MANAGEMENT PLANS FOR
EXISTING ANIMAL WASTE MANAGEMENT SYSTEMS SERVING FEEDLOTS
In order to be deemed permitted by the Division of Environmental Management
(OEM), the owner of any existing animal waste management system constructed and
operational before January 1, 1994 which is designed to serve greater than or
equal to the animal populations listed below is required to submit a signed
certification form to OEM before San ary 1, 1998. Pasture operations are
exempt from the requirement to be certified.
100 head of cattle -
75 horses
250 nwtze
1,000 sheep
30,000 birds with a liquid v"te aystan
The certification must be signed by the owner of the feedlot (and manager if
different from the owner) and by any technical specialist designated by the Soil
and Water Conservation Commission pursuant to 15A NCAC 6F .0001- .ODDS. The
technical specialist must verify that all applicable operation and maintenance
standards and specifications can be met. Existing systems are not required to
meet design and construction standards and specifications.
Although the actual number of animals on the facility may vary from time to time,
the design capacity of the waste handling system should be used to determine if
a farm is subject to the certification requirement. For example, if the waste
system for a feedlot is designed to handle 300 hogs but the average population
will be 200 hogs, then the waste management system requires a certification.
This certification is required by regulations governing animal waste management
systems adopted by the Environmental Management Commission (EMC) on December 10,
1992 (Title 15A NCAC 2H .0217)_
on the reverse side of this page is the certification farm which must be
submitted to OEM before January 1, 1998. Assistance in completing the form can
be obtained from one of the local agricultural agencies such as the Soil and
Water Conser-ration Cistrict, the USDA -Soil Conservation Service, or the N.C.
Cooperative Extension Service. The completed form should be sent to:
Department of Environment, Health and Natural Resources
Division of Environmental Management
Water Quality Section, Planning Branch
P.O. Box 29S35
Raleigh, N.C. 27626-053S
Phone: [phone]
Steve W. Tedder, Chief
Water quality Section
Form ID: ACEXIST0194
Date: 17- 07 IS5 3
P.O. Box 29535, Rdeigh, North Ccroiina 27626-0635 Telephone [phone] FAX [phone]
An Equd opoonunity Affirmcrtive Action Employer 5M recycied/ 1 o% post -consumer pcper

October 4. 1994
Mr. David Holsinger
DEHNR
Water Ouality Section, Planning Branch
P.O. Boa 29535
Raleigh, NC 27626-0535
Dear Mr. Holsinger:
I have recently purchased Keith Honevcut's 735 head finishing
operation. I have reviewed the approved Waste utilization plan
with SCS and it is understood and will be implemented.
Sinc ely,
vid Naylor
Enclosures

Departzent of Environment, Heals =Fand�Natu_ai Resou-ces
Division of Ezv_renmenzal Management
water Quality Section
if the animal waste manageme_nz system for your feedlot opera icn is
designed to serve more _:tan or equal to ;00 head of cattle, 73
horses, 250 swine, 1, 000 sheep, or 30, 000 birds 4"a= are served by
a __quid waste system, =ten this form must he filled out and :tailed
y December 31, 1993 pursuant == 15A NCAC 2 _.021 (c} in c=der to be
deemed permitted by DEM. f_ease print clearly.
=arm Name:
Mailing Address:
Wu'n .
Owner (s) Name:
manager(s) Name:
Lessee Name:
Farm Location (Be a specl; ` c as pcsslzie • toad names direction
m__Iepost, ! etc } --� •n .k rzi low I..1
C• 1 — r. r i . . rs . .. c. r 1 .
41
Lat_tude/Lcngrtn de if :mown: C��,S� �.5---r,, n ,�_�'2 `'2�'.
Design capacity of animal waste management system (Number and type
c: cznfined animal (s) } r'I
Average animal opulat*on of the farm (Number and type of animals)
raised)
Year Production Began: `J.' ASCS Tract No.
Type of 'waste Management System Used:
Acres Available for Land Application of waste: / 2 Arj-
Owner (s) Signature (s) :
_DATE: