620012_Other_20230614

Change of Swine Integrator Registration Form
Farm Name: n X' c ry-%
Facility Number: (e D, - 1 :�,
Physical Location of the Swine Farm: _ 4:15 V\ 3 -rs-e5
or - t1C_ —1 a Is
Owner(s) Name: R Gr V1
MailingAddress: Q 1 a
City, State, Zip Code:�� n�"1
Grower(s) Name if different than Owner:`
Mailing Address:
City, State, Zip Code:
9 4 ls� -q�
Phone: �t tU- Email: r"c- I lt—+
Current/New Integrator: kAD c �r o� c + a
Integrator Contact Name: _ V n --\, ,, -f S kr%
Mailing Address: � 0 - by ' S
City, State, Zip Code: A,..t�r.-<- sC�- vJ
Phone: °t 1 D - °► 3 ' 4 3+�mai1: w 2 -% r, s tY,'► i� . o ,�-,
l� y 1�3
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: [e-mail]
CISIR 03-25-2021