670002_Other_20230605

Change of Swine Integrator Registration Form
Farm Name: C C 1111 k5 'r
Facility Number:
Physical Location of the Swine Farm:
C)10'Lsu; l tc r oc_ ---
Owner(s) Name: —JL)o.V i X- . 1
Mailing Address: _
City, State, Zip Code:..
1
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: C1 k0- 3 eft - 11 l L. Email: A c-,o U r,,-& I C4—P t fC ar,-,
Current/New Integrator:
Integrator Contact Name: �U n -e 5 Imr,
LQ
Mailing Address:• �S
--�Ir
City, State, Zip Code: 3Q
Phone: CWD- D 00 - 94email: w 2 fir, S n-,•` � �� , Lo „�
Owner's Signature
z0�,-5
Dale
NVe appreciate your cooperation. This information is required in accordance with G.S. 143-215.101J. If
you have any questions contact the AFO Unit at [phone], other\vise 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 1S ENCOURAGED. PLEASE Eh AIL TO: [e-mail]
CIS1R 03-25-2021