540034_Other_20230524

Change of Swine Integrator Registration Form
Farm Name: Sec -or. 6-
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Facility Number: S!3_ - 4
Physical Location of the Swine Farm:
Owner(s) Name: _ _��\ Sc rN .r
Mailing Address: S C(a �� . '\-P= 5 04 �C \ l Y.L .
City, State, Zip Code:i
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code: --
Phone: 4-15a 4 S
Current/New Integrator: -
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Integrator Contact Name: V—� U Ir V
Mailing Address: SS(,a
City, State, Zip Code: D VZJ Y-1 L= $ 3Ct 1� R
Phone:(NlD-a93-943%mail:
Owner's Signature
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Date
We appreciate your cooperation. This information is required in accordance with G.S. 143-21 S.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