660021_Closure form and rescision request_20230427

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APPENDIX 3.1
Animal Waste Storage Pond and Lagoon Closure Report Form
(Please type or print all information that does not require a signature)
General Information:
Name of Farm: Srf-per,! i 12 ►,4o 41e s7 � Facility No:
Owner(s) Name: :m ie f • * L,&-o&J
Mailing Address: -2 Phone No: S 78 — 7ibf
r1A S CO C • a 7 9Y.r — 9 '36 County: 4 & i /Fr, a AAI
OD6ation Description (remainine animals only):
lease check this box if there will be no animals on this farm after lagoon closure.4If there will still be animals on the site
after lagoon closure, please provide the following information on the animals that will remain.
Operation Description:
Type of Swine No. of Animals
o Wean to Feeder
o Feeder to Finish
o Farrow to Wean
o Farrow to Feeder
o Farrow to Finish
o Gilts
o Boars Other 7j pe of Livestock. Number of Animals:
Will the farm maintain a number of animals greater than the 2H .0217 threshold? Yes o No
Will other lagoons be in operation at this farm after this one closes? Yes o No 6,"
How many lagoons are left in use on this farm?: MSA/C
Type of Poultry No. of Animals
o Layer
o Non -Layer
Type of Beef No, of Animals
o Brood
o Feeders
o Stockers
Type of Dairy
o Milking
oDry
o Heifers
o Calves
No. of Animals
(Name) .JQ of the Water Quality Section's staff in the Division of
Water Quality's kofA Regional Office (see map on hack) was contacted on 3 — 2 y- 2-3 (date)
for notification oZiclh
pending closure of this pond or lagoon. This notification was at least 24 hours prior to the
start of closure, wbegan on .3 — A 9— Z 3 (date).
I verify that the above information is correct and complete. I have followed a closure plan, which meets all NRCS
specifications and criteria. I realize that I will be subject to enforcement action per Article 21 of the North
Carolina General Statutes if I fail to properly close out the lagoon.
Name of Land Owner (Please Pitt): .J i /`+? Iti V / — • 0.9y
Date: !/— Z s .395Z3
The facility has followed a closure plan which meets all requirements set forth in the NRCS Technical Guide
Standard 360. The following items were completed by the owner and verified by me: all waste liquids and
sludges have been removed and land applied at agronomic rate, all input pipes have been removed, all slopes have
been stabilized as necessary, and vegetation established on all disturbed areas.
Name of Technical Specialist (Please Print):
Affiliation: 44
Address (Agency): NBC fi�C w.d Phone No.: W -J• TY-.T331
Signature:Date:_y a023
Return within 15 days following completion of animal water storage pond or lagoon closure to:
N. C. Division Of Water Quality
Animal Feeding Operations Unit
1636 Mail Service Center
Raleigh, NC 27699-1636
PLC - .1 March 18, 2002
MAi I r.J 14 - A5 - 23