820672_Application_20210504

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: t j \ t V% F., r �a c r, r .• Facility No: - Otai ' L
Previous Owner(s) Name: c . t J r2.3 Phone No:
New Owners) Name: rn_, Phone No: o - t -
New Farm Name (if applicable):
Mailing Address: i' i `$ �� it: = {7,6 4S*-
i
Farm Location: Latitude and Longitude: / County:
Please attach a copy of a county road map with location identified, and provide the location address and driving directions
below (Be specific: road names, directions, milepost, etc.):
Operation Description:
Type of Swine No. of Animals
❑ Wean to Feeder
❑ Wean to Finish
®' Feeder to Finish
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
Type of Swine
❑ Gilts
❑ Boars
No. of Animals
Type of Cattle No. of Animals
❑ Dairy
❑ Beef
Type of Poultry No. of Animals
❑ Layer
❑ Pullets
Other Type of Livestock: Number ofAnimals:
sa•-rn CsA.�r�;��o,i4, i7.,3�'A Fca.` .>=c-. r-NFO,>.
Acreage Available for Application: 1 ` -5 Required Acreage: r
Number of Lagoons / Storage Ponds: Total Capacity: `Ji/li'Cubic Feet (ft3)
********************************************************************x****************
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 constriction 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 stonn 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 Previous Land Owner:
Signature:.% '%v- Date: Ii--/,,›/z.t
Name of New Land Owner:
Signature: �l;� l`�_� Date: 1-Fly;ri/-Zl
Name of Manager (if different from owner):
Signature: Date:
Please sign and return this form to: Animal Feeding Operations
N. C. Division of Water Resources
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699-1636
June 12, 2015

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name:
Permit #:
Facility ID#:
- c' Y- County: 'C.:Ds- ..,.
Operator In Charge (OIC)
Name: 't..',
First Middle
Cert Type / Number:
5{`
f •O V I 'F1.T. S
Last
Signature: lc`k
Jr, Sr, etc.
Work Phone: (c--1) -
Date:
"I certify that I agree to my designation as the Operator in Charge for the facility noted. I understand and will abide by the rules and regulations
pertaining to the responsibilities set forth in 15A NCAC 08F .0203 and failing to do so can result in Disciplinary Actions by the Water
Pollution Control System Operators Certification Commission."
Back-up Operator In Charge (Back-up OIC) (Optional)
Name:
First Middle
Last
Cert Type / Number:
Jr, Sr, etc.
Work Phone: (
Signature:
Date:
"I certify that I agree to my designation as Back-up Operator in Charge for the facility noted. I understand and will abide by the rules and
regulations pertaining to the responsibilities set forth in 15A NCAC 08F .0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name: 11.',
Phone #: (`\ L :• )
Signature: , A,)
(Owner or authorized agent)
Fax#: ( )
Date: 4 1-
Mail, fax or einail the
original t0:
Mail or fax a copy to the
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center,
Email: certadminAncdenr.gov
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Raleigh, NC 27699-1618
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phoen: 910.433.3300
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Fax: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 05-2015
(Retain a copy of this form for your records)