820487_Other_20230501

Change of Swine Integrator Registration Form
Farm Name: Y, L r-
Facility Number: � $1
Physical Location of the Swine Farm: L�� 0 �-u S
Owner(s) Name: CG-rC
Mailing Address:
City, State, Zip Code: Lk LI
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code: W i r\ rS�C ✓ `b 34-1 _
Phone: a 1Q - ASS O - Email:
Current/New Integrator:
'.
�'c o(�L r�r1
Integrator Contact Name:
�`1 : +r1
-e %
Mailing Address: �• 0 - --E:, t v Cd S
City, State, Zip Code: .<- S -- vJ _, n C— . % 3Q
Phone: Ol 1 D - a c 3 - 44 3YTmail: Kw 9:a:� +t- r, CT?- S tom'% L o ,-,
Owner's Signature Date
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