760008_Owner (Affiliation Change)_20221017

Change of Swine Integrator Registration Form
Farm Name:
Grover Ea(tA5
Facility Number: I l7 - nkcg
Physical Location of the Swine Farm:
4iN f\U\\ V.
Owner(s) Name: 1 \_/' A.1,/"' J
Mailing Address: CI —LA
City, State, Zip Code: 63NLP
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: Email:
Current/New Integrator:
Integrator Contact Name:
Mailing Address:
31 ',LAMnK�� ��H
City, State, Zip Code:-- Lau rt n
Phone: a `(�-,'ilh4-1.g Email:
VC& 4r .
Owner's Signature
S'"n i cow.
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