Title Page
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Site
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Conducted on
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Prepared by
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Location
Part 1 - Farm Review
Water Usage
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What is the source of irrigation water? (Pond, Stream, Well, Municipal, Other)
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Please specify
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How are crops irrigated? (Flood, Drip, Sprinkler, Other)
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Please specify
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A water quality assessment has been performed to determine the quality of water used for irrigation purpose on the crop(s) being applied.
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A water quality assessment has been performed to determine the quality of water use for chemical application or fertigation method.
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If necessary, steps are taken to protect irrigation water from potential direct and nonpoint source contamination.
Sewage Treatment
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The farm sewage treatment system/septic system is functioning properly and there is no evidence of leaking or runoff.
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There is no municipal/commercial sewage treatment facility or waste material landfill adjacent to the farm.
Animals/Wildlife/Livestock
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Crop production areas are not located near or adjacent to dairy, livestock, or fowl production facilities unless adequate barriers exist.
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Manure lagoons located near or adjacent to crop production areas are maintained to prevent leaking/overflowing, or measures have been taken to stop runoff from contaminating the crop production areas.
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Manure stored near or adjacent to crop production areas is contained to prevent contamination of crops.
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Measures are taken to restrict access of livestock to the source or delivery system of crop irrigation water.
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Crop production areas are monitored for the presence or signs of wild or domestic animals the entering the land.
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Measures are taken to reduce the opportunity for wild and/or domestic animals from entering crop production areas.
Manure and Municipal Biosolids
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Please choose one of the following options as it relates to the farm operations:
Raw Manure
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When raw manure is applied, it is incorporated at least 2 weeks prior to planting or a minimum of 120 days prior to harvest.
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Raw manure is not used on commodities that are harvested within 120 days of planting.
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If both raw and treated manure are used, the treated manure is properly treated, composted or exposed to reduce the expected levels of pathogens.
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Manure is properly stored prior to use.
Composted Manure
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Only composted manure and/or treated biosolids are used as a soil amendment.
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Composted manure and/or treated biosolids are properly treated, composted, or exposed to environmental conditions that would lower the expected level of pathogens.
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Composted manure and/or treated biosolids are properly stored and are protected to minimize recontamination.
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Analysis reports are available for composted manure/treated biosolids.
No Manure/Biosolids Used
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No animal manure or municipal biosolids are used.
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A previous land use risk assessment has been performed.
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When previous land use history indicates a possibility of contamination, preventative measures have been taken to mitigate the known risks and soils have been tested for contaminants and the land use is commensurate with test results.
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Crop production areas that have been subjected to flooding are tested for potential microbial hazards.
Traceability
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Each production area is identified or coded to enable traceability in the event of a recall.
Conclusion: Part 1 - Farm Review
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Comments/Recommendations:
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Farm Review
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Name and Signature