670030_Other_20230511

Change of Swine Integrator Registration Form
Farm Name:
Facility Number: %-1 3 C_
Physical Location of the Swine Farm: a: S . J r so .
5-1 LV
Owner(s) Name: (2--
Mailing Address:
f4k
City, State, Zip Code: 1 C� V a s 5-1 L4
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: Q I O - Q '�L4 - `{17`) Email:
Current/New Integrator: S
Integrator Contact Name: � C-\ •e S Vt'+r'
Mailing Address: �• • --e> iz:� c6- S La
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City, State, Zip Code:
Phone: % O - a c 13 - 9 `i 3'smail: �,-� 2S -�,-, 5 cY, •� .� �� . L o m
We appreciate your cooperation. This information is required in accordance with G.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