540141_Other_20230501

Change of Swine Integrator Registration Form
Farm Name: C 1 [k r C%N C-.E!- Sm t Van A-, v,
Facility Number: 5y_ - 1 `i l
Physical Location of the Swine Farm: a k 0 Li
Owner(s) Name: C C, r rr.►
Mailing Address: aLA -; 1 L .
City, State, Zip Code: -e s5 LA Z2
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: a5 a - Sian - \ %-k 6 '3 Email: l �o rJ ir�o c • C- 0 Y1—
Current/New Integrator:
Integrator Contact Name: �6Q \) 1-1 _ �] •� S ,n
Mailing Address: �. �] , C� �L _ c6— S La --
City, State, Zip Code:.n C— 1 % SCI
Phone: c l 110 - a q 3 ' - 4 3$mai1: Ke-S +t�- r, C-,�-_ s 4%-% -�i -p— \L , L o rr
ZLO-7-2 c �-
Owner's Signature
Date
2-3
We appreciate your cooperation. This information is required in accordance with G.S. 143-215.10H. 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