310256_Other_20230606

Change of Swine Integrator Registration Form
Farm Name; _-- ��"i.e..� 1 _ �w t'a44%-Q_Y- s Iwc w.
Facility Number: _ ----A � Zn _
Physical Location of the Swine Farm:l�
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Owners) Name:
Mailing Address: _ S
City, State, Zip Code:._
Grower(s) Name if different than Owner:
Marling Address: - -
City, State, Zip Code:
Phone:''tlq--Email:. C►,-,'S a mop;' .C—c cY,
Current/New Integrator: L>
Integrator Contact Name: Y-%
Mailing Address:
S5 (a --
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City, State, Zip Code: _
Phone: LO -2L 53 - 3 3mail:
Owner's Signature
Dale
We appreciate your cooperation. This information is required in accordance with G.S. 1.43-215.10H. If
you have any questions contact the AFO Unit at [phone], otherwise please return this form to:
NC Division of Water Resources
Water Quality Pei:mitting 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