960064_Other_20230531

Change of Swine Integrator Registration Form
Farm Name: V i , r,.. -t „
Facility Number: ct In - LqtA
Physical Location of the Swine Farm: q-1 [� V-K
Owner(s) Name: � k ry-%
Mailing Address: r� S
City, State, Zip Code: ��� a- n ct i-1 C �SSS 1
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code -
Phone: q kcL
- j- 6,.L,jLjEmaiI: b1clke . 9rcjy7lj Cj y�til7ao
Current/New Integrator: S -tom-. - Q La e kAroC t_� on
Integrator Contact Name: \Z-�il : rN % kti,r,
Mailing Address: �• 0 . --k-?=, b1L C6-S La
City, State, Zip Code: 1, � r„tir S C- Y L L I % 3 R <�5
Phone: 9 1 D-al53-3�i Lrrnail: 4Ls+r.—G-R- S rn*i ceLo rr�
S �y a3
Owner's Sign re Dat
We appreciate your cooperation. This information is required in accordance with G.S. 143.21 S.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 F.MA1L TO: RAMESH.RAVELLAQaNCDENR.GOV
CISIR 03-25-2021