310223_Other_20230615

Change of Swine Integrator Registration Form
Farm Name: (' D 1 h P (-�SO r� VC Y- rY---.
Facility Number: 3— - 0��3
Physical Location of the Swine Farm: L40 to Ck fC
AhpcNS©n. 1::� C ;).g5g
Owner(s) Name:
Mailing Address: �' ��-A .�. k 0�
City, State, Zip Code: L ►ZQ -�y� n tlC $ 3 �r1
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: Qi Ln- 3CS -1 (A;'. Email:
Current/New Integrator: s V-rl.-, , V c Vlvn� 5,
Integrator Contact Name: VVQ-\j -e S V br.
Mailing Address: �• b ` S
City, State, Zip Code: i abv :K 'Z, c- n —. ; � S. 00 SR �S
Phone: Olt D - a a 3 - 343email: Ksv-3 cs+tz:- r%C,--)- S r-, . 4ln-k V-- Lo
Owner's Signature Date
We appreciate your cooperation. This information is required in accordance with G.S. 143-215.101-1. 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 EMAIL TO: [e-mail]
CISIR 03-25-2021