310770_Other_20230614

Change of Swine Integrator Registration Form
Farm Name:
Facility Number: 3 1 '-1-1 0
Physical Location of the Swine Farm: "S t-1,1
c n
Owners}Name: r' �- '► � M o. n 1, LL
Mailing Address: LV Ll C-ft
City, State, Zip Code:
Grower(s) Name if different than Owner: rSk-�� \
Mailing Address:
City, State, Zip Code:
Phone: a15 - S40 - R g2 Email: _m.� irsr L °l"13 C&- 2 r' • C� �.
Current/New Integrator: S �•• -tom, V a kAt) "?v-a( ` . '-,�
Integrator Contact Name: --N S r
Mailing Address: �• b C � S
City, State, Zip Code: ,t S c,-- v.' Yr1 C— $ 3 R
Phone: CL 1 D - a 9 3 - 43 ail:. � �, � 2 5"b r-, C� S c� � �-�i•�i� . L o rr,
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