310247_Other_20230616

Change of Swine Integrator Registration Yorm
Farm Name:
Facility Number., 3 1 - 'aq-1 _--
Physical Location of the Swine Farm:
-311
Mailing Address:
City, State, Zip Code: M�..-. %
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: Email:
Current/New Integrator:
a
integrator Contact Name:
Mailing Address:
12 'S`� . .....
City, State, Zip Code:, - IR1-k
Phone. axu--D,53":-- � +-mail:
Signature Date
We appreciate your cooperation. This information is required in accordance with G.S. 143-215. 1 OH. 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: RA1Y1ESH.RAVELLA@,NCDENR.G0V
CISIR 03-25-2021