310055_Other_20230522

Change of Swine Integrator Registration Form
Farm Name:�--
Facility Number:_ -�
Physical Location of the Swine Farm: LILA -� l � V o- Jo.rvn•e.S _ f 1 .
1�ar ncr 8
Owner(s) Name:
Mailing Address:
City, State, Zip Code: �n�.n�u i �1e tl tiq
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: Rto - aq In ` 3 O SEmail: In k b J - r ep- ►^+ • l . C cn
Current/New Integrator: - S t-c�'. t�- V)U� 'roc s .� n
Integrator Contact Name: •Q ri -e % Vt�n
Mailing Address: �• S
City, State, Zip Code: K vJ YZ $ 3ck S--,_
Phone: Al l D - a C13 - 3 �t3'Vmail: QS -� r� ��` - 5 tY, �-�h z .e- L o
j a K&eS 1pj o KoeS 5/22/2023
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