740041_Owner (Name Change)_20210112 (2)

Notification of Change of Ownership
Animal Waste Management Facility
(Please type or print all information that does not require a signature)
In accordance with the requirements of 15A NCAC 2T .1304(c) and 15A NCAC 2T .1305(d) this form is official notification
to the Division of Water Resources (DWR) of the transfer of ownership of an Animal Waste Management Facility. This
form must be submitted to DWR no later than 60 days following the transfer of ownership.
General Information:
Previous Name of Farm: F DV_ tn1 :.d Facility No: 1- [ lg
Previous Owner(s) Name: Leo. • 4 Arit & _ Phone No:
New Owner(s) Name: rte., Po ,G Rr, .. s L 1 C Phone No: 2-5-7,-- )14 -101�,
New Farm Name (if applicable):
Mailing Address: _ ! o 3 3 t,temuk-t_t (),rifc,ujte. Ak Zc 10
Farm Location: Latitude and Longitude: 1 County: ?t 77
Please attach a copy of a county road map with location identified, and provide the location address and driving directions
belowspecific: road names directions, milepost, C I• S G ' i
(Be
(Ba sp ns, mil st, etc.): Fr o� n.trl r
Operation Description:
Type of Swine No. ofAnimals Type of Swine No. ofAnimals Type of Cattle No. ofAnimals
❑ Wean to Feeder ❑ Gilts ❑ Dairy
❑ Wean to Finish ❑ Boars ❑ Beef _
Cl Feeder to Finish —3 pi W
❑ Farrow to Wean Type of Poultry No. ofAnimals
❑ Farrow to Feeder ❑ Layer —_
❑ Farrow to Finish ❑ Pullets
Other Type of Livestock: Number ofAnimals:
Acreage Available for Application: 91- S Required Acreage:
Number of Lagoons / Storage Ponds: Total Capacity:i ( 03 $OO Cubic Feet (ft3)
Owner / Manager Agreement
I (we) verify that all the above information is correct and will be updated upon changing. I (we) understand the operation and
maintenance procedures established in the Certified Animal Waste Management Plan (CAWMP) for the farm named above
and will implement these procedures. I (we) know that any modification or expansion to the existing design capacity of the
waste treatment and storage system or construction of new facilities will require a permit modification before the new
animals are stocked. I (we) understand that there must be no discharge of animal waste from the storage or application
system to surface waters of the state either directly through a man-made conveyance or from a storm event less severe than
the 25-year, 24-hour storm and there must not be run-off from the application of animal waste. I (we) understand that this
facility may be covered by a State Non -Discharge Permit or a NPDES Permit and completion of this form authorizes the
Division of Water Resources to issue the required permit to the new land owner.
Name of Previtt Lan nevi [ e v-. ft e,r t L
Signature: 1.4`-V Date: IL- - 1- 2-3
Name of New Land Owner: n Grzf ti F.l R ra-.
Signature: Ii� Date: ` 2-
Name of Manager (if different from owner):
Signature: DabtimeitneoN
Please sign and return this form to: Animal Feeding Operations
N. C. Division of Water Resources QZQZ 9133a
RED Water Quality Regional Operations Section
1636 Mail Service Center
Z�Zd Raleigh, NC 27699-1636 Q 1B33i3
DEC 15 June 12, 2015
NC DEG!DWR
Central Office