410016_Other_20230501

Change of Swine Integrator Registration Form
Farm Name: _- L\�`�-e_-oL
Facility Number: 14- _ _ X Lo
Physical Location of the Swine Farm: -to ins 3 S •' I tied V-A �-
Owners) Name:
Mailing Address:
City, State, Zip Code: (-)L
Growers) Name if different than Owner.
Mailing Address:
City, State, Zip Code:
Phone: t-3 — is ti- l ail: �,�. ,�.1 e��tar,, �,, ra h1
Current/New Integrator:
Integrator Contact Name:' r} .e S+r�
Mailing Address: ���
City, State, Zip Code: C Y1L S�'►'
Phone: 9l I D — D. 013 — � 3 mail: -- 2 - Y-, � S c� : �� . L a
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 Peimitt+ng Section
Animas Feeding Operations
1636 Mail Service Center
Raleigh, NC 27699-1636
ELECTRONIC SUBMISSION IS ENCOURAGED. PLEASE EMA.II. TO: RAMESH.RAVELLA [e-mail]
CISIR 03-25-2021