310822_Other_20230524

Change of Swine Integrator Registration Form
Farm Name:
Facility Number: 3 $D,a
Physical Location of the Swine Farm: -� Oc) �� c� Qr lo�� L n
Owner(s) Name: _ ��� �_ ti�-ram `. o- rr. L_G. r;► ,r
Mailing Address: i�Ca�Ov�n�o��,���►� _
City, State, Zip Code:
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: RHO - X1 L— U to I Email:
I f'\C_ a.�5DI
Current/New Integrator: r-n, T�_� - �'roC —`.0 +r1
Integrator Contact Name: \4VQ_\1 -, r-% -e S r1
Mailing Address: • C6- 5 La
City, State, Zip Code: _ u__� pti<- S , n C— I % 3Q
Phone: Cl l D — a 53 ' 34N�mai1: 25 -b r, G;;;;� S rn�, 4kN-�i.���
jw,jold 0— �W� 6- , 2-7
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