800017_Application_20220104

RECEIVED
Notification of Change of Ownership JAN MA 2022
Animal Waste Management Facility
(Please type or print all information that does not require a signature) Q/DWR
In accordance with the requirements of 15A NCAC 2T .1304(c) and 15A NCAC 2T .1305(d) tiis`form is oTfiefi0aation
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: (p
Previous Name of Farm: A t i--/ (! I I .s 'Croy,
Previous Owner(s) / Name• [,y J 4/y . s (h ,- � y: J
New Owner(s) Name: iksr, 4
New Farm Name (if applicable): ,, ff��^^
Mailing Address: 187 5 !f f Dd4T 7d 'lr ('hdv4 ►L� Cat N
•d t� 22013
Farm Location: Latitude and Longitude: 3 j o LI i ' 0 0#' / s-0` yS' %s1I County: rq 0 LkAst n
Please attach a copy of a county road map with location identified, and provide the locationt`address and driving directions
below (Be specific: road names, directions, nnulepost, etc.): f f 7 3O 1 �� L� i �q tes_s R o' 6.R 1253')
1Q , +. TKber t' kttr R0__(..5R.oUJ 4-krn t...�es-f n 41-.� i_, e..
Fa r p, is co -r„- 1-. -cr A+ , Ta . 0 r 6 h wr e- L kat ,
Operation Description:
Type of' Swine No. of Animals Type of Swine No. of Animals Type of Cattle No. 9/Animals
❑ Wean to Feeder 0 Gilts G1i airy 300
❑ Wean to Finish 0 Boars 0 Beef
❑ Feeder to Finish
❑ Farrow to Wean Type of Poultry No. of Animals
❑ Farrow to Feeder 0 Layer
❑ Farrow to Finish 0 Pullets
Other Type of Livestock: A Number of nimals:
Acreage Available for Application: 31r
9 . J c .c. Required Acreage: (5-6 et. L
Number of Lagoons / Storage Ponds: / Total Capacity: / 3 S,, Li g S Cubic Feet (ft3)
Owner / Manager Agreement
1 (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 (wc) 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. 1 (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 re 'red permit to thez ew land owner.
z
wner:
n n
f � �
Name of Mana er (if different from owner): 7� 1 . --
Signature: 1 1 >� ) u(t Ui v V
Name of Previous
Signature:
Name of New La
Signature:
Please sign and return this form to:
Facility No: 5 0 -
Phone No:
Phone No: 2'4t 00a 66d
Date: Ir2
Date:
Date: - 9)
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