520015_Other_20230601

Change of Swine Integrator Registration Form
Farm Name: ,. � a =— IN U
Facility Number: S -
Physical Location of the Swine Farm:
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Owner(s) Name: , 9-%-% „ , .... `� ... ._ ...
Mailing Address .:._ ,..._.. .. ._v� �t�—. .3 ......_
City, State, Zip Code:
Growers Name if different than Owner:
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Mailing Address ._. ��� ._��.��_�a_ . mw _ _ _ ........
City, State, Zip- r` �5...$..
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Code: \ ..._......
Phone: 4141 Email:
Current/New Integrator:„
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Integrator Contact Name: w : r...S,r.
Mailing Address:. .. ........."S _ La_ ..
City, State, Zip Code: S r,-
Phone: '2\ 1 D -a S3 ' 34 �Lvmail:. �. --?...9 « ...� n
Owner's Signature
J�- �-< < adjv-c5S C 1,e-`r r
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