960182_Other_20230619

Change of Swine Integrator Registration Form
Farm Name: cJt�P 41, M 5
Facility Number: RLy - M2-
Physical Location of the Swine Farm: act-13 oy
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Owner(s) Name: -
Mailing Address: 2xr�na. -
City, State, Zip Code:
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: A1A - �1a.1-- `� j 1 Email: Q%.% e
Current/New Integrator: k,r 1 - 12n
Integrator Contact Name: 5J t S �^
Mailing Address: - S
City, State, Zip Code: K S3Q
Phone: °t 1 D - a °13 - 943kVmail: � w �s � n � sue-, � . � 1� . c-
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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 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: R.AMESH.RA1'EL.LA®NCDENR.GOV
CISIR 03-25-2021