540037_Other_20230601

Change of Swine integrator Registration Form
Farm Dame:
Facility Number:
Physical Location of the Swine Farm:
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1
Owner(s) Name'. CLC V, Ut.-C-
Mailing Address:
City, State, Zip Code:u--
Grower(s) Name if different than Owner -
Mailing Address:
City, State, Zip Code:
Phone:at�;A-rj to a — tG'wFjc Email: e i C. +�• ., t�'L-�
Current/New Integrator:
integrator Contact Name: sa ti % u- % � �j -e % khr.
Mailing Address: �. •L 5(,Q
-- --
City, State, Zip Code: _.i�._. rat C vJ Y-L
Phone: °t 1 D — a 9 3 " 3 33 ail:
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 AAFO 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: RAIvIESH.RAVEI LA@NCDE'NR.GOV
CISIR 03-25-2021