03-2010

Please print or type

(For WVDEP use only) Permit Application No. WV___

WV DEPARTMENT OF ENVIRONMENTAL PROTECTION

DIVISION OF WATER AND WASTE MANAGEMENT

CONCENTRATED ANIMAL FEEDING OPERATION (CAFO) APPLICATION

1.Operation Status (Check One)Existing OperationProposed Operation

2.Name of Operation______

3.Physical Location

Street, Road, or HighwayCityCounty

4.Owner

5.Owner Telephone Number( )

6.Operator

7.Operator Telephone Number( )

8.Operation Mailing Address

Street or Box Number

CityStateZip Code

9.Contact Person Title

Contact E-mail Address______

Contact Phone Number()

Contact Fax Number()

10.Coordinate Data of the Production AreaLatitude

Longitude

11.Name of USGS 7.5 Minute Topographic Map

APPLICANT MUST ATTACH A TOPOGRAPHIC MAP OR A COPY OF A PORTION OF THE TOPOGRAPHIC MAP SHOWING THE SPECIFIC LOCATION OF THE PRODUCTION AREA

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12.Types and Number of Animals

Animal Type / Number of Animals in Confinement / Number of Animals Housed Under Roof
Mature Dairy Cows
Dairy Heifers
Veal Calves
Cattle (not dairy or veal)
Swine (55 lbs. or over)
Swine (under 55 lbs.)
Horses
Sheep or lambs
Turkeys
Chickens (Broilers)
Chickens (Layers)
Ducks
Other - Specify:
TOTAL ANIMALS

13.Manure, Litter, and/or Wastewater Production and Use

a)How much manure, litter, and process wastewater are generated annually by the operation?

Tons or Gallons (Circle the appropriate unit)

b)If land applied, how many acres of land under the control of the applicant are available for applying the CAFO operation’s manure, litter and/or process wastewater?

Acres

c)How many tons of manure or litter, or gallons of process wastewater produced by the CAFO operation will be transferred annually to other persons?

Tons or Gallons (Circle the appropriate unit)

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14.Type of Containment, Storage, and Capacity

Type of Containment / Total Capacity
(in gallons)
Lagoon
Holding Pond
Evaporation Pond
Other: (Specify)
Provide the total number of drainage acres contributing runoff: acres
Type of Storage / Total Number of
Storage Days / Total StorageCapacity
(gallons or tons)
Anaerobic Lagoon
Storage Lagoon
Evaporation Pond
Aboveground Storage Tanks
Below Ground Storage Tanks
Underfloor Pits
Roofed Storage Shed
Concrete Pad
Impervious Soil Pad
Other: (Specify)

15.CAFO Nutrient Management Plan (NMP) Information

Applicant must attach a copy of the operation’s approved NMPto this CAFOApplication.

a)Was the CAFO NMP developed and/or approved by a certified Nutrient Management Planner?

_____Yes _____No

b)Please provide the name, title, and/or agency and of the person who developed and/or approved the NMP: ______

c)Is the CAFO Nutrient Management Plan being fully implemented for thisfacility? _____Yes______No

d)Pleaseprovide the date that the CAFO’s NMP was last approved or revised? (Date)______

e)If the facility is not land applying, please describe all alternative use(s) of the manure, litter, and /or process wastewater from the operation. _____

______

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16.Land Application Best Management Practices

a)If applicable, please check any of the following best management practices that are being implemented at the operation to control runoff and protect water quality.

____Buffers_____Setbacks_____Conservation Tillage

____Constructed Wetlands_____Infiltration Field_____Grass Filter

____Terrace_____Other: (Specify)______

17.CERTIFICATION

I certify under penalty of law that this document and all attachments were prepared under my direction or supervision in accordance with a system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based upon my inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information, the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are significant penalties for submitting false information, including the possibility of fine and imprisonment for knowing violations.

A. Name and official title (Print or type) / B. Phone No.
C. Signature / D. Date Signed