960185_Integrator Registration_20220614

Change of Swine Integrator Registration Form
Farm Name: i Q+`
Facility Number: "110 - bWS
Physical Location of the Swine Farm; 1 S tip, jRO ,q d
Owners Name:—l-J c S r ,� VJRittl2Alit
Mailing Address: 3 / j i
City, State, Zip Code: /:- ,2 -,,--N A. _ ( 2.'7
Grower(s) Name if different than Owner:
Mailing Address: S.tm rnr
City, State, Zip Code:
Phone: 9 J i7 �L Email:
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Current/New Integrator 6 ectrV 1 evv Farniteb LL-C,
Integrator Contact Name: l Mk V1'C
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Mailing Address: 1 _5B O�
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Phone: C 10 r)(l O abiS Email: bOri r y i�[t (� � � � 1Y�('i ► Cotn
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City, State, Zip Code:
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 Permitting Section
Animal Feeding Operations
1636 Mail Service Center
Raleigh, NC 27699-1636
ELECTRONIC SUBMISSION IS ENCOURAGED. PLEASE EMAIL TO: RAMESH.RAVELLA c@NCDENRGOV
CISIR 03-25-2021