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FORM FOR DOCUMENTING BACKFLOW PREVENTION 4 OF _�'� UNDER WASTE DISCHARGE REQUIREMENTS GENERAL ORDER NO. 1135-2013-0122 FOR EXISTING MILK COW DAIRIES f �4uSL�� This form consists of six parts and can be used to document compliance with the requirements in Waste Discharge Requirements General Order No. R5-2013-0122 for owners/operators of existing milk cow dairies (Dischargers) to: 1. Identify cross-connections that would allow the backflow of wastewater into a water supply well, irrigation well, or surface water as identified on the dairy's Site Map; 2. Propose and schedule corrective action to prevent backflow of wastewater into a water supply well, irrigation well, or surface water as identified on the dairy's Site Map; and/or 3. Document there are no cross-connections that would allow the backflow of wastewater into a water supply well, irrigation well, or surface water as identified on the dairy's Site Map. The Discharger must complete this form except for Parts IV and V, which are to be completed by a trained professional'. Both the owner and the operator of the dairy must sign the certification statement in Part VI. Additional sheets may be attached as necessary to complete Parts I, II, and III. A Site Map must be attached to this form that shows all water supply wells, irrigation wells, and surface water bodies in the dairy's Production Area and all Land Application Areas that are under the Discharger's control. The Site Map must also show all wastewater conveyance structures, wastewater discharge points to surface water, and where wastewater is mixed/blended with fresh irrigation water in these areas. Each of these locations must be identified by a name or number and listed in Part II below. Completion of Part II will identify how backflow can or does occur at each location and any current backflow preventive measures. PART I: DAIRY FACILITY INFORMATION A. Name of Dairy or Business Operating the Dairy: Mello Ranch B. Physical address of Dairy: 27181 E. Carter Road Escalon San Joaquin 95320 Number and Street City County Zip Code C. Operator Name: Jarred Mello Telephone No: 209-573-3748 Operator mailing address: PO Box 22 Escalon San Joaquin 95320 Number and Street City County Zip Code D. Owner Name: Jarred Mello Telephone No: 209-573-3748 Owner Mailing Address: PO Box 22 Escalon San Joaquin 95320 Number and Street City County Zip Code ' A trained professional could be a person certified by the American Backflow Prevention Association, an inspector for a state or local governmental agency who has experience and/or training in backflow prevention, or a consultant with such experience and/or training. Page 1