640011_Closure Report form_20230307

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: a F((tl f1i Facility No:_,,'+`-
Owner(s) Name:_,
Mailing Address: 1V751 Wa _. Rl)L 1l11 01 kaCy.._ {• ,�"1$°I1 _Phone No: M2-50 �
County:,
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.
Ooeration Descrintion:
Ttpeofswine No. ofAuirrtals
o Wean to Feeder
o Feeder to Finish
o Farrow to Wean
o Farrow to Feeder
o Farrow to Finish
o Gilts,
o Boars
TtpeofPoultr_r No. of",•lrrimals
o Layer _
o Non -Layer
Tipe of Beef No. of -Animals
o Brood
o Feeders _
o Stockers
Other Tigre ofLirestock:__
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`.'
Hoye many lagoons are left in use on this farm?:
Typeof'Dairy No. of Animals
o Milking
o Dry
o Heifers
o Calves
Numher olAninials:
Yes o No 9
Yes o No s
(Name).,Am of the Water Quality Section's staff in the Division of
Water Quality's , r a l _ _ Regional Office (see nrup oa bud.) was contacted on_I - (elate)
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 -1.- 20- 2022 (elute).
I verify that the above information is correct and complete. I have followed a closure plan, which meets all NRCS
specifications and criteria. 1 realize that 1 will be subject to enforcement action per Article 21 of the North
Carolina General Statutes if 1 fail to property close out the lagoon.
Name of Lang Owner (Please Print): e 1 a e
Signature:
Dater -) : :i
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) L, hSi
Affiliation:___ -
Address (Agen y):.0.iT%.. ( /�/ �_ Z,lC/_J9 __Phone No. Z5Zw�2
Signature: _ Date:,j1,'Z%
Return within 15 days following completion of animal water storage pond or lagoon closure to:
N. C. Division Of Water Quality
Animal Feeding Operations Unit
1636 Mail Service Center
Raleigh, NC 27699-1636
PLC - i March 18, 2002