740014_Other_20230525

Change of Swine Integrator Registration Form
Farm Name: Vn6-rlon m'A\5 ti+
Facility Number: y - V—
Physical Location of the Swine Farm: 3 \01 p-e%tV 'Seel. �L_
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Owner(s)Name: �6N+i\'S o rrr. L1-�
Mailing Address: �� ia� �fJe\ e1n� S�e-A— \Z-1
City, State, Zip Code:, L I`,Yl�te.(oA YlC_ :IZ�5q D
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone:D,%- 3LU- 3 2,4 4 Email:
Current/New Integrator:
Integrator Contact Name: l,•Q-Ql -, r1 \ �J •e S kbrn
Mailing Address: �• 0 • -I& b\L 6S (a.
City, State, Zip Code: \-X
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u--) YA L_
a. % Sq
Phone:Qt10-act3`943
ail:
Y\%O s+t r%Cc,
Srn', Corr,
Owner's Signature Date
We appreciate your cooperation. This information is required in accordance with G.S. 143-215.IO1-1. If
you have any questions contact the AFO Unit at [phone], otherwise please return this form to:
NC Division of Water Resources
Water Quality Peimitting 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