310788_Other_20230522

Change of Swine Integrator Registration Form
Farm Name: J `4- J A:-,,-, a
Facility Number: _3_ -IS "ir_
Physical Location of the Swine Farm: J 1 3 �•�_
�FLSQ ,�)L- ass39 l
Owner(s) Name: n ' - _�_ ate-
Mailing Address: 1S to v . C-0�'
City, State, Zip Code:
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: (1D - OLFt io— a S % Email: , '� J `
Current/New Integrator: C: r-c�•► ''C� �'ra f1
Integrator Contact Name: Q , r
Mailing Address: _ �• es LQ
City, State, Zip Code: \ __) os.�: C r,= uJ n C_ -
Phone: Ql1 D - a 5 3 - 9 4 3LVmail:
01 K4,,S,s gj 5/22/2023
Owner's Signature Date
We appreciate your cooperation. This information is required in accordance with G.S. 143-215.1011. 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@,NCDENR.GOV
CISIR 03-25-2021