510065_Rescission Request_20221116

Name of Lanr wner (
Signature:!
Name of Farm;
General Information: nn j (�'
arc s" 4`��GL-.C.rr..SG1 -` ,rin.
Owner(s) Name: �U £ C-- ��•
Mailing Address: l S l
Animal Waste Storage Pond and Lagoon Closure Report Form
(Please type or print all information that does not require a signature)
Periv41r 3 a Au S 5 S ob 6 S
Facility No:
•
Phone No: •1'1t4t-tg - ?oS
e_r.s!, o a`t 561t- g n I County: "sex
Operation Description. (remaining animals only):
VPlease 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:
Type ofSwine No. ofAnimals Type ofPoultry , No. ofAnimals Type ofDaity No. ofAnimals
o Wean to Feeder o Layer o Milking
o Feeder to Finish o Non -Layer o Dry
o Farrow to Wean Type of Beef No. ofAnimals o Heifers
o Farrow to Feeder o Brood o Calves
o Farrow to Finish o Feeders
o Gilts o Stockers
o Boars Other Type ofLivestock:• Number ofAnimals:
Will the farm maintain a number of animals greater than the G.S. § 1.43-215.1DOB threshold? Yes o No o
Will other lagoons be in operation at this farm after this one closes? Yes o No V
How many lagoons are left in use on this farm?:
(Name) of the Water Quality Regional Operations Section staff in the
Division of Water Resources' Regional Office (see map on back) was
contacted on . (date) for notification of the pending closure of this pond or lagoon. This notification
was at least 24 hours prior to the start of closure, which began on (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.
lease Print). C. Mai c.r..(}
t
Date: 9-
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):
Affiliation: U, v ;apt c1F f.J ie647„,g,Uv n
Address (Agenc : •.1. }4 in 'oe+eg C1'1 / tt �4, #6 17 4u 3Phone No.: // 9 ' 7a 7 —37 9 `!
/
Signature: ( l!� Date: �/ i
61,r;s. Loy,
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. 2011