820383_Remission (Request)_20220916

Animal Waste Storage Pond and Lagoon Closure Report Form
(Please type or print all information that does not require a signature)
General Information: t
Name of Farm: e :,,� rw�. i.,,j�;�1(..�,:a Facility No:? �� - �)
Owner(s) Name:
O
Mailing Address: Phone No: ` ( )
County: ..� L\ V17),) ,` r
O eration Description (remaining animals only):
Please check this box if there will be no animals on this farm after lagoon closure. If there will still be animals on the site after
lagoon closure, please provide the following information on the animals that will remain.
Operation Description:
Typeof Swine No. of Animals Type of Poj r y No. of Animals
0 Wea?rtoFeeder ❑ Layer,.„
0 Feeder to Finish 0 Non-Layeelw.
0 Farrow to We Type of Beef i 'b,,of An.intals
0 Brood `''�,
0 Farrow to FeederN...
..
0 Farrow to Finish
0 Gilts
0 Boars
N
0 Feeders
0 Stockers
Other Type of Livestock:
Type of D q, y No. of Animals
❑ Milking
O Dry
0 Heifers
O Calves
Number of Animals:
Will the farm maintain a number of animals greater than the G,S, § 143-215.I0B threshold? Yes ❑ No 4.
Will other lagoons be in operation at this farm after this one closes? Yes LI No,t4
How many lagoons are left in use on this farm?: (1 %
(Name) of the Water Quality Regional Operations Section staff in the
Division of Water R so aces' ;1 .Q i-. 5-V i i r:- Regional Office (see map on back) was
contacted on '/ 3 V I (date) for notYfication of the pending closure of this ?ond or lagoon. This notification was
at least 24 hours prior to the start of closure, which began on 3 i' �i'l t>t /�� r,; (date).
I verify that the above information is correct and complete. I have followed a closure plan, which meets all NRCS
specifications and criteria. I realize that I will be subject to enforcement action per Article 21 of the North Carolina
General Statutes if I fail to properly close out the lagoon.
1 �0 (/ ) (-A
Name of Land Owner (Please Print):
Signature: f1 AA
Date: 4,
The facility has followed a closure plan which meets all requirements set forth in the NRCS Technical Guide Standard
360, The following items were completed by the owner and verified by me: all waste liquids and sludges have been
removed and land applied at agronomic rate, all input pipes have been removed, all slopes have been stabilized as
necessary, and vegetation established on all disturbed areas.
Name of Technical Specialist (Please Print): t/ (
Affiliation: Afi,/. < ' ; i i , : - i }f5 E !Di',
Address (Agency): ` _5 / `��,,'t _("t 1)
Signature: ,�i/(.ztf'
L'E < Phone No.: 1(( 1 i C t:d f/j
Date:
Return within 15 days following completion of animal water storage pond or lagoon closure to:
N. C. Division of Water Resources
Animal Feeding Operations Branch
1636 Mail Service Center
Raleigh, NC 27699-1636
PLC - 1 Nov 19, 2013