960200_Other_20230606

Change of Swine Integrator Registration Form
Farm Name: ff
Facility Number: Ci(Q„
Physical Location of the Swine Farm: 1 a
k C-
Owners) Name: 0
Mailing Address: 40-- Y-
City, State, Zip Code:
Grower(s) Name if diffcvw than Owner. - -
Mailing Address:
City, State, Zip Code:.
Phone: ckkc1- f' 2.;k - !j135 Email:
Q rr
CurrentJNew Integrator:
Integrator Contact Name: %j , ry -eS Vt�-r-,
Mailing Address: n -"& '6S (a
City, State, Zip Code: •r u.3 Y1 L
Phone: a 1 fl -, ack3 ' 4 3%naii:
-- Owner's SignatP, �=� ;/j� & - �- -;L --,7
ge Date
We appreciate your cooperation. This information is required in accordance with G.S. 143 215.14H. 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 G0V
CISIR 03-25-2021