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APPENDIX 3.1
Animal Waste Storage Pond and Lagoon Closure Report Form
(Please type or print all information that does not require a signature)
General Information:
Name of Farts:_� M.� �/ /C. �Awoa.J �At.�.eaa �AJ7� _Facility No: O y
Owner(s) Name: f `.•�.r, A4�ac�
Mailing Address: 212'-wwS Phone No:,2c5"3 —S ?&•-wo j
OrAc40 AIX . 278YC- Q4-36 County: Ale & .v
escription (remaininaanimals onl :
10qease check this box if there will be no animals on this farm after lagoon closure. If there will still be animals on the site
after lagoon closure, please provide the following information on the animals that will remain.
One fation Detention:
Type of Swine No. of Animals
o Wean to Feeder
o Fader to Finish
o Farrow to Wean
o Farrow to Feeder
o Farrow to Finish
o Gilts
o Boars
Type of Poultry No. of Animals
o Layer
o Non -Layer
Type of Beef No. of Animals
o Brood
o Feeders
o Stockers
Other Type of Livestock.•
Will the farm maintain a number of animals greater than the 2H .0117 threshold?
Will other lagoons be in operation at this farm after this one closes?
How many lagoons are left in use on this farm?: O Al Q.
Type of Dairy No. of Animals
o Milking
o Dry
o Heifers
o Calves
Number of Animals:
Yes o No ::��
Yes o No Y
(Name) S Aie T �. �� of the Water Quality Section's staff in the Division of
Water Quality's RAWeA Regional Office (see map on back) was contacted on V-L- Z 3 (date)
for notification of the pending closure of this pond or lagoon. This notification was at least 24 hours prior to the
start of closure, which began on ..I - 23 (date).
I verify that the above information is correct and complete. l have followed a closure plan, which meets all NRCS
specifications and criteria. I realize that I will be subject to enforcement action per Article 21 of the North
Carolina General Statutes if I fail to properly close out the lagoon.
Name of Land der (Please Prime r;
Date: S�Z/ZOTt3
The facility has followed a closure plan which meets all requirements set forth in the NRCS Technical Guide
Standard 360. The following items were completed by the owner and verified by me: all waste liquids and
sludges have been removed and land applied at agronomic rate, all input pipes have been removed, all slopes have
been stabilized as necessary, and vegetation established on all disturbed areas.
Name of Technical Specialist (Please Print):.l 1,1/11/4M
Affiliation: r
Address (Agency: Q - C f it 140A dAk Phone No.: A -eJ
Return within 15 days following completion of animal water storage pond or lagoon closure to:
N. C. Division Of Water Quality
Animal Feeding Operations Unit
1636 Mail Service Center
Raleigh, NC 276"-1636
PLC - I March 18, 2002