960070_Other_20230614

Change of Swine Integrator Registration Form
Farm Name: 3 o-r v-%,e 5 `� -�, -X�-,r' ,
Facility Number: C� L —10
Physical Location of the Swine Farm: LA U
Owner(s) Name: eS
Mailing Address: U O r'
City, State, Zip Code: �p ��-r� ��� f l aS E-6 1
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: ,D c; a, - 5 S q - 3 9'33 Email: �}�r1h • � � 1-.� Q--�� 5 &,, N aV-. CP -- ram. l . L o �►
Current/New Integrator:
Integrator Contact Name: �y : n >J S kbr,
Mailing Address: �• 5 S LQ
City, State, Zip Code: l-L at- YZL 13ci <�S-
Phone: ill O- a c1 - 343ail: 14w e-�-br� 5 �•� �� 1� . Lo �
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