400029_Other_20230523

Change of Swine Integrator Registration Form
Farm Name:
Facility Number: 40 ;kA_
ttSS
Physical Location of the Swine Farm: MGrn S ?) Q inl
Owner(s) Name: cQ` rA
Mailing Address:
City, State, Zip Code: s ro.-o SC3
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: a5a— 559t-- 01CL Email: °L
Current/New integrator: S t,,•. -7�_ aC
Integrator Contact Name: �• \i ,
Mailing Address: �• • —I& izz� v C6- S L
City, State, Zip Code: �,�) of s- S a= u> . YL t- I % 3Q ZS
Phone:glO—acN3`34?LF-mail: itwes-l->r,62 Sr-,'+4hR's- c—o.,r,
Owner's Signature Date
We appreciate your cooperation. This information is required in accordance with G.S. 143-215.101-1. If
you have any questions contact the AFO Unit at [phone], otherwise please return this form to:
NC Division of Water Resources
Water Quality Permitting Section
Animal Feeding Operations
1636 Mail Service Center
Raleigh, NC 27699-1636
ELECTRONIC SUBMISSION IS ENCOURAGED. PLEASE EMAIL TO: RAMESH.RAVELLA cQNCDENR.GOV
CISIR 03-25-2021