CAFO Application07-2012
Page 1
Please print or type.
Permit Application No. WV______(For WVDEP use only)
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
Owner Telephone Number( )
5.Operator (if different from Owner)
Operator Telephone Number( )
6.Operation Mailing Address
Street or Box Number
CityStateZip Code
7.Contact Person Title
Contact E-mail Address______
Contact Phone Number()
Contact Fax Number()
8.Coordinate Data for the Production AreaLatitude______
Longitude______
9.Receiving Stream(s) for the Production Area
10.***Attach a topographic map, or a copy of a portion of the topographic map, showing the specific location of the Production Area*** (Attach map to application)
(Please continue on page two)
11.Types and Number of Animals
Animal Type / Number of Animals in Confinement / Number of Animals Housed Under RoofMature 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
12.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)
(Please continue on page three)
13.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
Under-floor Pits
Roofed Storage Shed
Concrete Pad
Impervious Soil Pad
Other: (Specify)
14.CAFO Nutrient Management Plan (NMP) Information
***Applicant must attach a copy of the operation’s approvedNMPto 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 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. _____
______
(Please continue on page four)
15.Land Application Best Management Practices
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)______
16.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
We will process your personal information (email address, mailing address and/or telephone number) in accordance with the State of West Virginia’s Privacy Policy for appropriate and customary business purposes. Your personal information may be disclosed to other State agencies or third parties in the normal course of business or as needed to comply with statutory or regulatory requirements, including Freedom of Information Act requests. The Division of Water and Waste Management will appropriately secure your personal information. If you have any questions about our use of your personal information, please contact the DEP’s Chief Privacy officer at .