760010_Owner (Affiliation Change)_20221031

Change of Swine Integrator Registration Form
Farm Name: tee elj n Jc ret> 0n
Facility Number: 7to10 - r' /
Physical Location of the Swine Farm: ' I/OO SLtkct Arm I
544; 4 /tic ziwo
Owner(s) Name: CI ✓l3 RC CJIn j
Mailing Address: /S % 141 6+o!barn eel ,C JopI Ai LUC 2 7ffD
City, State, Zip Code:
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone:
Email:
h
Current/New Integrator: c7@n'1 i4h`Fie lG' Perk
Integrator Contact Name: Jell Los/ le.
Mailing Address: J)-c M Cte%ti cD '
City, State, Zip Code: (_CAUri Il `\OUffie- a-1.1a-
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Phone: (bilkZia 007 Email a� D IUS r-®sMiti-t 'c % J Cows
CA— A %R / 13,1 G z
Owner's Signature Date
We appreciate your cooperation. This information is required in accordance with G.S. 143-215.10H. If
you have any questions contact the AFO Unit at [phone], otherwise please return this form to:
NC Division of Water Resources
Water Quality Permitting Section
Animal Feeding Operations
1636 Mail Service Center
Raleigh, NC 27699-1636
ELECTRONIC SUBMISSION IS ENCOURAGED. PLEASE EMAIL TO: [e-mail]
CISIR 03-25-2021