250007_Other_20230502

Change of Swine Integrator Registration Form
Farm Name: /-4 C .
Facility Number: a 3 -
Physical Location of the Swine Farm: SZ4t 1 -Z>zN4 t- A0(-4 Er nw4 l l ?.1L
Owner(s) Name:
Mailing Address:
City, State, Zip Code: k.r ,
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: aS '�- SW l V Email: S\-�� r\ -Car rr. S (%S 4 Q 54 (ip- l . C- O �
Current/New Integrator:
Integrator Contact Name: �• 'j -, n V I-) -e % Vt�r %
Mailing Address: • O• SS
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City, State, Zip Code: �n►_t' C' o.. (�S-
Phone: Ol l D - a a13 ` 3 4 3%mail: Kw e s -}o ►-� C: s �, - �. �� . L o .,r-,
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s Signature v 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: RAMESH.RAVELLAQNCDENR.GOV
CISIR 03-25-2021