540071_Other_20230614

Change of Swine Integrator Registration Form
Farm Name: 1'<' cs' -)�-o W \
Facility Number: 5 Lj_ - --I 1
Physical Location of the Swine Farm: 53 O_�o �Qaf C(-Q-¢- K g�-
Owner(s) Name:
LLL
Mailing Address:
City, State, Zip Code: -p-Qra ns; l 5 5 I
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone:t' 1� ar QCYMCL,�o
Current/New Integrator: ` "
Integrator Contact Name: f %
La
Mailing Address: k, V SS
City, State, Zip Code: Mr 5, e:- � � - Yl
Pbone: (' 1 D- k93 - 2tf3-mail: kw 2S br+t'► 5 ram'• `r:�\� . LO rv-�
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