520015_Other_20230531

Change of Swine Integrator Registration Form
Farm Name: IX _
Facility Number: Ste_ - \ 5
Physical Location of the Swine Farm: —7 c\ CAA
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Owners) Name: 9\: c3g-,� 1 - — -
Mailing Address: d
City, State, Zip Code: `� �+� 7* '
Grower(s) Name if different than Owner.
MailingAddress: j _ 't P—Oacl-
City, State, Zip Code: 1 're rA-or�, �� $
Phone: Q5a— a I4- ` a.4 Z Email:
Cm-ent/New Integrator. t��. ---PV-0AA, r AA DrN
Integrator Contact Name: �Q i r1 k tj - S kbr,
Mailing Address: �- . --e> 6S La
City, State, Zip Code: c c. •� lr1 3Q
Phone: Pa D - a c 13 - 943%nai1:
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Owner's Signature f Date
SA C , A T (:! 1- <- `r r
We appreciate your cooperation_ This information is required in accordance with G.S. 143 215.1OH. 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 SUBNIISSION IS ENCOURAGED. PLEASE EMAIL TO: [e-mail]
CISIR 03-25-2021