260059_Application_20230320

Notification of Change of Ownership
Animal Waste Management Facility
(Please type or print all information that does not require a signature)
In accordance with the requirements of 15A NCAC 2T.1304(c)and 15A NCAC 2T.1305(d)this form is official notification
to the Division of Water Resources (DWR) of the transfer of ownership of an Animal Waste Management Facility. This
form must be submitted to DWR no later than 60 days following the transfer of ownership.
General Information: / II _
Previous Name of Farm: Co 1(1 cr 1-6 FYK 5- Facility No: _-
Previous Owner(s)Name: i ut �le.n a t l;r( Phone No:<1 -CL
New Owners)Name: tut-Ot-, L, -- _ —Phone No:9/0
New Farm Name(if applicable): w ea� gip✓ �Irr+�S
Mailing Address: 4'i -F vtIre 6 C, 2-83l1 rr
F'arni Location: Latitude and Longitude: .3SO & QI- f/ 7t*.a$ 5,314 W County:
Please attach a copy of a county road map with location identified,and provide the location address and driving directions
below(Be specific:road names,directions,milepost,etc.): q 100 EaS(A1 44 111W e_ )VI�f
Operation Description:
Type ofnvine No. ofAnInials Type ofStvine No. of All imals Type of Cattle No. ofAnininls
13 Wean to Feeder 17 Gilts ❑Dairy
®`Wean to Finish ❑Boars ❑Beef
0 Feeder to Finish
D Farrow to Wean. Type of Poulby No.ofAnin al,s
17 Farrow to Feeder ❑Layer
13 Farrow to Finish ❑Pullets
Other Type of Livestock Number of Animals:
Acreage Available for Application: 6?_ •35- Required Acreage:
Number of Lagoons/Storage Ponds: Total Capacity: Cubic Feet(ft3)
Owner/Manager Agreement
I(we)verify that all the above information is correct and will be updated upon changing. I(we)understand the operation and
maintenance procedures established in the Certified Animal Waste Management Plan(CAWMP)for the farm named above
and will implement these procedures. I (we.)know that auy modification or expansion to the existing design capacity of the
waste treatment and storage system or construction of new facilities will require a permit modification before the new
animals are stocked. I (we) understand that there must be no discharge of am I aste froin the storage or application
system to surface waters of the state either directly through a man-made conveyance or from a storm event less severe than
the 25-year,24-hour storm and there must not be run-off from the application of animal waste. I(we)understand that this
facility may be covered by a State Non-Discharge Permit or a NPDES Permit and completion of this form authorizes the
Division of Water Resources to issue the required permit to the new land owner.
Name of Prevla L�jd Owner: ;` - "
Y
Signature- L://� —Date: -
Name of New Land Owne ruK
Signature: /( _rr-^--- Date: .3l
Name of Manager(if di erent from owner).
Signature: / Date:
Please sign and return this form to: Animal Feeding Operations
N.C.Division of Water Resources
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh,NC 27699-1636
6, Wav
�Ti

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F.0201
Facility/Farm Name: f W i 52 61 J��� W►h5 - - ----
Permit#: _ Facility IDi#: 2�& - 59 County;
V16
Operator In Charge(OTC) r/��
Name: wAs G)et, % L a� ,.v- 0�\ ��/`
First Middle l Last Jr,Sr,etc.
Cert Type/Number:_ ()1 (, Work Phone: ( 910
Signature: L!L9 - Date:
"I certify that I agree to my designation as the Operator in Charge for the faeility noted.I understand and will abide by the rules and regulations
pertaining to the responsibilities set forth in 15A NCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the Water
Pollution Control System Operators Certification Commission"
Back-up Operator In Charge(Back-up OTC) (Optional)
Name:
First Middle Last Jr,Sr,etc.
Cert Type/Number: Work Phone:
Signature: - Date:
"I certify that I agree to my designation as Back-up Operator in Charge for the facility noted.I understand and will abide by the rules and
regulations pertaining to the responsibilities set forth in 15A NCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name: I<e►,A e41— /Z -
Phone#: (910 Fax#: i