520009_Change of Integrator Form_20230419

Farm Name.
Facility Number:
Physical Location of the Swine Farm C;
. ........ ... ...
Owner(s) Name:
Mailing Address:
C) 5 City, State, Zip Code: I I r, k- L z>
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: cMS\ Email: V-QCr.�X\'% VN is t4
Current/New
Integrator Contact Name: '14�Q -, V-%
Mailing Address: '6S (.,a
City, State, Zip Code:
Pbone:c�iZ-a�-3--.?>li3LI�maii:
O�.... . ... ...........
wner's�—Signature
Zoe
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