540004_Change of Integrator Form_20230419

G.
Change of Swine Integrator Registration Form
Farm Name:
Facility Number
Physical Location of the Swine Farm:
Owner(s) Name:
Mailing Address: • U
City, State, Zip Code:,
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
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phone: ,5 0 -,0 Email: r 0 -v<p C \xp '�� 0-C S -
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CurrezutVuw Integrator:
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Integrator Contact Name: y1j) -e
Mailing Address: C-
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City. state, Zip Code: L.
Phone:
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Signature
Date
We appreciate your cooperation. This information is required in accordance with G.S. 143-215.101d. 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: RAMESH.RAVELLA@NCDENR-GOV
CISIR 03-25-2021