670009_Other_20230427

Notification of Change of Ownership
Animal Waste Management Facility
(Please type or print all information that does not require a signature)
In accordance with the requirements of 15A NCAC 2T .1304(c) and 15A NCAC 2T .1305(d) this form is official notification
to the Division of Water Resources (DWR) of the transfer of ownership of an Animal Waste Management Facility. This
form must be submitted to DWR no later than 60 days following the transfer of ownership.
General Information:
i
Previous Name of Farm:_ O��Y%fj C 5 yt --'A ' Facility No:
Previous Owners Name: r i ��t o .Y_ Phone No: Q i�-- Ct 1%
New Owner(s) Name: �.t; x, _ c�,,r r� rs Ire _ Phone No:_
New Farm Name (if applicable): -
Mailing Address: _ QA% r ter-. �. r �]r1 � _i ����� 4. � `L
Farm Location: Latitude and Longitude:Z�i' 5—V 51e / as W' �_4e County:
Please attach a copy of a county road map with location identified, and provide the location address and driving directions
below (Be specific: road names, directions, milepost, etc.): Oc- S 1 ;�► ram. rox. ` �rY, ► l�
Operation Description:
Type of Swine No. ofAnimals Type of Swine
lean to Feeder 7S"AP O GiIts
❑ Wean to Finish ❑ Boars
❑ Feeder to Finish
E3 Farrow to Wean
❑ Farrow to Feeder
E3 Farrow to Finish
Other Type of Livestock:
Acreage Available for Application: • =.
No. ofAnimals
Number ofAnimals:
Required Acreage: ' n . y
Type of Cattle
❑ Dairy
❑ Beef
Type of Poultry
O Layer
❑ Pullets
Number of Lagoons / Storage Ponds: Total Capacity: �,��S - Cubic Feet (ft3)
No. ofAnimals
No. of Animals
Owner / Manager Agreement
I (we) verify that all the above information is correct and will be updated upon changing. I (we) understand the operation and
maintenance procedures established in the Certified Animal Waste Management Plan (CAWMP) for the farm named above
and will implement these procedures. I (we) know that any modification or expansion to the existing design capacity of the
waste treatment and storage system or construction of new facilities will require a permit modification before the new
animals are stocked. I (we) understand that there must be no discharge of animal waste from the storage or application
system to surface waters of the state either directly through a man-made conveyance or from a storm event less severe than
the 25-year, 24-hour storm and there must not be run-off from the application of animal waste. 1 (we) understand that this
facility may be covered by a State Non -Discharge Permit or a NPDES .Permit and completion of this form authorizes the
Division of Water Resources to issue the required permit to the new land owner.
Name of Previous Land Owner: C 0. rJ • �,_ n O r
Signature: 1 j�L S� _ Date:
Name of New Land Owner: s D Y _
Signature: _ V Date:,
Name of Manager (if different from owner);
Signature: Date:
Please sign and return this form to:
Animal Feeding Operations
N. C. Division of Water Resources
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699-1636
June 12, 2015

Change of Swine Integrator Registration Form
Farm Name: See---,
Facility Number:
Physical Location of the Swine Farm: l 00-1- Gm- r2c�r
Owner(s) Name:
Mailing Address:
City, State, Zip Code: r QuAo&,�'] 1l _- _-,-L C_ 2), S51
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone:%%_ Q$ — j Q qm Email:
Current/New Integrator: res
Integrator Contact Name: �Q ` rti -e % k-bv-,
Mailing Address: �• C) • ct5 cS La
City, State, Zip Code: I%
Phone: dl1 L� JCL
Owner's Signature Date
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

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name: �'S f�U,.ir
Permit #: _(1 "—i coo 01Facility ID#: it - 001 County:
Operator In Charge (OIC)
Name: _ i S.
First Middle
kc, V nCr^
Last Jr, Sr, etc.
Cert Type / Number: _ _I 61_ 4 1� Work Phone: ((Al b
Signature:. C047_ Date:
"I certify that I agree to my designation as the Operator in Charge for the facility noted. I understand and will abide by the rules
and regulations pertaining to the responsibilities set forth in ISA NCAC 08F .0203 and failing to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
Bach -up Operator In Charge (Back-up OIC) (Optional)
First Middle Last Jr, Sr, etc.
Cert Type / Number:
Signature: _._._ , -
Work Phone:
Date:
"I certify that I agree to my designation as Back-up Operator in Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities set forth in 15A NCAC 08F .0203 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name: __30.rl% n 0 r
Phone #: i- t p) `C)U LA Fax#: t
Signature: _ lrlt�hZgmt)
Date:
_(Ov)n
Mail or fax to: WPCSOCC
1.61.8 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]
(Retain a copy of this form for your records)
Revised 8t2007