Annual Report Concentrated Animal Feeding Operations {52510}

CONCENTRATED ANIMAL FEEDING OPERATION ANNUAL REPORT State Form 52510 (R3 / 11-12) National Pollutant Discharge Elimination System Concentrated Animal Feeding Operation (NPDES CAFO) INDIANA DEPARTMENT OF ENVIRONMENTAL MANAGEMENT Confined Feeding Section Office of Land Quality 100 North Senate Avenue MC 65-45, IGCN 1101 Indianapolis, Indiana 46204 (800) 451-6027 extension 2-4473 INSTRUCTIONS: A person with a facility subject to 327 IAC 15-16 must submit an annual report to the commissioner by February fifteenth (15 ) of each year for the previous calendar year with the following information. For each permitted facility, this form must be completed, signed, th dated, and submitted to IDEM prior to February 15 of each year during permit coverage to update facility information and activities for the previous calendar year. th I. GENERAL INFORMATION A. FACILITY INFORMATION NPDES CAFO Individual Permit Number: Facility Name: Location Address: City: State: County: Name of water body receiving drainage from production area: (stream/creek/river/ditch) Telephone: Facsimile: ZIP Code: B. CONTACT INFORMATION Owner Name: Address: City: Operator Name: Address: City: State: Telephone: Facsimile: ZIP Code: Telephone: Facsimile: ZIP Code: Telephone: Facsimile: ZIP Code: State: C. COMMERCIAL MANURE HAULER (if applicable) Name: Address: City: II. COMPLIANCE INFORMATION A. DISCHARGE INFORMATION State: Has the facility had a discharge of manure, litter, or process wastewater from the production area in the previous twelve (12) months? If yes, on a separate sheet list the date, time, and approximate volume of each discharge. Attach any and all sheets to this form. This information is a requirement of 40 CFR 122.42(e)(4)(vi). B. MANAGEMENT AND REPORTING REQUIREMENTS Has the facility had an instance of non-compliance with either management requirements or reporting requirements in the previous twelve (12) months? If yes, on a separate sheet detail all instances of non-compliance. Attach any and all sheets to this form. Note: Spills must be reported to IDEM within two (2) hours of discovery in accordance with 327 IAC 2-6.1-7. <Continued on Reverse> Yes (check one) No Yes (check one) No American LegalNet, Inc. www.FormsWorkFlow.com III. CONCENTRATED ANIMAL FEEDING OPERATION CHARACTERISTICS A. TYPE AND NUMBER OF ANIMALS Sector Cattle or Cow/Calf Pairs: Mature Dairy Cattle: Veal Calves: Swine: (weighing less than 55 pounds) Number in Open Number Housed Confinement Under Roof MANURE, LITTER, AND/OR PROCESS WASTEWATER PRODUCTION AND DISPOSAL 1. Estimated amount of total manure, litter, and process wastewater generated by the facility in the previous twelve (12) months. B. tons/gallons/cubic feet (circle unit) Swine: (weighing more than 55 pounds) Horses: Sheep and Lambs: Turkeys: Laying Hens and Broilers: (liquid manure handling system) 2. Estimated amount of total manure, litter, and process wastewater transferred to other persons by the facility in the previous twelve (12) months. tons/gallons/cubic feet (circle unit) Chickens Other Than Laying Hens: (other than a liquid manure handling system) 3. Amount of acreage owned, leased, or covered in land use agreements that the permittee has access to for applying manure, litter, and process wastewater generated by the facility. acres Laying Hens: (other than a liquid manure handling system) Ducks: (other than a liquid manure handling system) Ducks: (liquid manure handling system) Other: (specify) 4. Amount of acreage owned, leased, or covered in land use agreements that the permittee utilized in the previous twelve (12) months for applying manure, litter, and wastewater generated at the facility. acres Total Animals: IV. NUTRIENT MANAGEMENT PLAN 1. Are you currently implementing a Nutrient Management Plan (NMP)? 2. Was your current NMP developed or approved by a certified nutrient planner? Yes Yes No No Please submit the following to the agency with this report to meet the requirements of 327 IAC 15-16-10 and 40 CFR 122.42(e)(4): Actual crop planted and actual yields for each field used for land application per your NMP. Soil test results for any land application fields tested in the 2012 calendar year. Test results for the phosphorous and nitrogen content of manure, litter, and process wastewater applied in the 2012 calendar year. Results of calculations performed to develop field specific application rates based on phosphorous and/or nitrogen levels in the field. The amount of any supplemental fertilizer applied during the 2012 calendar year. Actual amounts of manure, litter, and process wastewater applied to each field in the 2012 calendar year. V. CERTIFICATION I affirm that the information on this form is, to the best of my knowledge and belief, true, complete and accurate. I am aware of the penalties for knowingly submitting false information under IC 35-44-2-1. A. NAME AND OFFICIAL TITLE (print or type) B. TELEPHONE NUMBER C. SIGNATURE D. DATE SIGNED (month, day, year) American LegalNet, Inc. www.FormsWorkFlow.com