800016_Other_20230207

APPENDIX 3.1
Animal Waste Storage Pond and Lagoon Closure Report Form
(Please type or print all information that does not require a signature)
General Information:
Name of Farm: ©SbOOt vtA-
Owner(s) Name: C t O- 1:113 Co 7Nc
Mailing Address: q oca '7/3f 40-S v I 1
Facility No: So -
Phone No: 7o y' g 73 ✓ s7 rY
County: Q
Operation Description (remaining animals only):
o 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:
Type of Swine No. of Animals Type of Poultty No. of Animals Type of Dairy No. of Animals
o Wean to Feeder o Layer o Milking
o Feeder to Finish
o Farrow to Wean
o Farrow to Feeder
o Farrow to Finish o Feeders
o Gilts o Stockers
o Boars Other Type of Livestock:
Will the farm maintain a number of animals greater than the 2H .0217 threshold?
Will other lagoons be in operation at this farm after this one closes?
How many lagoons are left in use on this farm?:
(Name) MI eCt e r Re / / / 4 of the Water Quality Section's staff in the Division of
Water Quality's PI ez ate—Regional/Office (see map on back) was contacted on 3 —1 `j /(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 (-[ / " / 6 (date).
o Non -Layer o Dry
Type of Beef No. of Animals o Heifers
o Brood o Calves
Dr9
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
Name of Land Owner (Please Print): ' �' ` r ' " �� �� ���R ��(} C frt.
Si nature: Date: 3
g
Carolina General Statutes if I fail to properl close out the lagoon.
Number of Animals:
Yes o
Yes o
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): C(f i
Affiliation:
Address (Agency),
Signature:
Phone No.: 7S - 5 I ®g4:'j
Date:
Return within 15 days following completion of animal water storage po
N. C. Division Of Water Quality
Animal Feeding Operations Unit
1636 Mail Service Center
Raleigh, NC 27699-1636
PLC - 1 March 18, 2002
045148
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0434