310814_Other_20230501

Change of Swine Integrator Registration Form
Farm Name: a+-�- t� l �o�rm5
Facility Number: �1 `9 1q
Physical Location of the Swine Farm: e - Y.- 8— .
Owner(s) Name:
A -
Mailing Address: n r,.
City, State, Zip Code: k La S
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: "1 Off , \ �l_1-Email:
Current/New Integrator: t-c�'.t�� _�_a_ �"ro Cr-1
Integrator Contact Name: •Q v r-N -e S ri
Mailing Address: • `6- S La
City, State, Zip Code: r c_YA3R
Phone: Ol l O - a 5 3 - 343LVmai1: e-S ±%�, ►'� - 5 n'-, art �i� . L o r. ,
Owner's Signature
Date
We appreciate your cooperation. This information is required in accordance with G.S. 143-215.1011. 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