670025_integrator change_20230605

Change of Swine Integrator Registration Form
Farm Name:
FacilityNumber: Ce1 - a5
Physical Location of the Swine Farm: ID Ct'
nc c3k, 1%1
Owner(s) Name: r V
Mailing Address:
City, State, Zip Code: �� \ �� $ �-
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: q10-35 6- 3 7 15 , Email: C �L �Ln -�, @ cry,": A.C-
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Current/New Integrator: 2> W-N"
Integrator Contact Name: 1�\j -, r, V-�-3 -e S Vt�r,
Mailing Address: �• b \,�- ": �6- S L
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City, State, Zip Code: LA-D -,c- S cw vJ , Y-1 C— �. %, 3Q z5 -
Phone: % O - a q 3 - 3 4 3' mail: e-+t- r, 'S . L O m
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