960137_Rescission Request_20230527

APPENDIX 3.1
Animal Waste Storage Pond and Lagoon Closure Report Form
(Please type or print all information that does not require a signature)
General Information:
Name of Farm: p C f\ -5 —�opn �Qc m Facility No: - 13�
Owner(s)Name: �\CV-%( _A '``t&1 Ln c c%,�4
Mailing Address: Z( 1 ��r k 17�r Phone No:9 A- 2Z 7--1`101
.
)c e-u�k\-2 , QC Z-71`�0 3 County: L U n X!&
Operation Description (remainiw,t animals only):
o Please check this box if there will be no animals on this farm after lagoon closure. If there will still be animals on the site
after lagoon closure,please provide the following information on the animals that will remain.
Operation Description:
Type of Swine No. of Animals Type of Poultry No. of Animals Type of Dairy No. of Animals
o Wean to Feeder o Layer o Milking
o Feeder to Finish o Non-Layer o Dry
o Farrow to Wean Type of Beef AG—of2nimals o Heifers
o Farrow to Feeder o Brood _ o Calves
o Farrow to Finish o Feeders
o Gilts o Stockers -
o Boars Other Type of Livestock: Number of Animals: _
;e��
Will the farm maintain a number of animals greater than the 2H .0217 threshold? Yes o 140\
Will other lagoons be in operation at this farm after this one closes? Yes o No\
How many lagoons are left in use on this farm?:
(Name) of the Water Quality Section's staff in the Division of
Water Quali %Wp Regional Office (see map on back) was contacted on 44 � 1 q�Z (date)
for notification of the pending closure of this pond or lagoon. This notification was at least 24 hours prior to the
start of closure,which began on LA�29. 2 -A (date).
I verify that the above information is correct and complete. I have followed a closure plan,which meets all NRCS
specifications and criteria. I realize that I will be subject to enforcement action per Article 21 of the North
Carolina General Statutes if I fail to properly close out the lagoon.
Name of Land Owner(Please Print):
Signature: Date:
Date• �, ��
The facility has followed a closure plan which meets all requirements set forth in the NRCS Technical Guide
Standard 360. The following items were completed by the owner and verified by me: all waste liquids and
sludges have been removed and land applied at agronomic rate, all input pipes have been removed, all slopes have
been stabilized as necessary, and vegetation established on all disturbed areas.
Name of Technical Specialist(Please Print): S)P&C" _w�r2s
Affiliation: '
Address (Agency : 3() J a fah, ;a l 0[1 16566 Phone No.:
Signature: Dater,?y1
R day lowing completion of animal water storage pond or lagofAlgJJJgAg6:
N. C.Division Of Water Quality mwd/wa ON
(2 7 20n Animal Feeding Operations Unit
MAY 27 2
1636 Mail Service Center Ezoz L ti �dW
NC DEQ/pig% Q%py� , Raleigh,NC 27699-1636
Central Offic Office
PLC - 1 March 18,2002