090101_Other_20230615

Change of Swine Integrator Registration Form
Facility Number: Q c,
Physical Location of the Swine Farm:"
Owner(s) Name: -1- t- c • ie A 1 C_� on2a� 1�
Mailing Address:
O
City, State, Zip Code:._ \,�4g
Grower(s) Name if different than Owner: 2)0�D
Mailing Address:
City, State, Zip Code:
Phone: Q 1,0 — 'Sr
tg :), - I 44'AEmaii: �Do L U %t �r. osl t t4- r: ���...� , reA-
Current/New Integrator:
Integrator Contact Name: �. \,} : V-. k & .e S r.
Mailing Address: �. C) . --& b v '6S La
City, State, Zip Code: �-k �) r,,--c' F, at-- vJ n [_ $ ?j
Phone: Ol 1 D — R3Vinail i,� �S +M r % -. Low,
Fiil0t,vzc ito 6vt-12q (j
AImu YC2.
��z
Owner's Signature Date)
We appreciate your cooperation. This information is required in accordance with G.S. 143-215.1011. 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