310251_Other_20230614

Change of Swine Integrator Registration Form
Farm Name:e-�� �5 c
Facility Number: _31 A S 1
Physical Location of the Swine Farm: �=i -1 �o� fl❑ ��p.'r M
Owner(s) Name: r ' k Corn o-f\L
Mailing Address: LkLk D, CQ : S�6_
City, State, Zip Code: _�x \�4.k.r k Sn n
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: ASQ.- 96Z) -(:kbct'A. Email: nR� hr`���-�o►'i3�O�rr . � Chi �'
Current/New Integrator: J� -cam•. T D
Integrator Contact Name: Y= V n k �J - S Vt�'r'
Mailing Address: �• VS to
City, State, Zip Code: r c-3Q (75
Phone: C� 1 O- 219 3- 9 4 3LP-mail: L o rv-,
�'Lti �a_O�D Rom- 6 -/�
Owner's Signature Date
We appreciate your cooperation. This information is required in accordance with G.S. 143-215.1OH. 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