540002_Change of Integrator Form_20230419

Change of Swine Integrator Registration Form
Farm Name: V-n
Facility Number: 54 0k,
,-Physical Location of the Swine Farm:
Owner(s) Name: %
Mailing Address:
R. �' �a
City, State, Zip Code: v,
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code: .. ...... ...
Phone: 5sj Email: f- o
rv,
Current/New Integrator:
Integrator Contact Name:
Mailing Address:
City, State, Zip Code:
Phone: % a CN'3 `2>43° mafi-
Owner's Signature Date
We appreciate your cooperation. 11is information is required in accordance with.. O.S. 143-215. 101`1. 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