860030_Owner (Affiliation Change)_20211123

Change of Swine Integrator Registration Form
Farm Name: LvkNd
(rier'L
-1--Afi74/
Facility Number: t!j - 3 b
Physical Location of the Swine Farm: / i (j L(A/41 13.q S�7 L N
M n N� oct
Owner(s) Name: ) ` 11 k t !�1 �p �/►/s(//1/
Mailing Address: PO et) y ). j
City, State, Zip Code: S 1 0 6t M NC - 7 Li 7
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: 3 3� �d 1" 963 Email: al. k P � V ivNSQ N �,L 1 OV v-iwo LO /11
Current/New Integrator:
$P\:I-C/d K�a's
Integrator Contact Name: R Lk C 11«`N5
Mailing Address: 3 JS >�L /I S-k-e-e—/—
City, State, Zip Code: LA -ilk ' I N bL1(E/ t I V L. e3 5 .
Phone: '"r f 0—) J11-OqCf yEmail: _ La II,'NS ,ri�1114 r C Id + L r1
1-43
Owner : gnature 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: [e-mail]
CISIR 03-25-2021