310051_ChangeIntegratorForm_20230621

Change of Swine Integrator Registration Form
Farm Name: nJ;, ri-1 a -Vo.'re,r, -- k=-Wox'I�, ir,-CA-
Facility Number: 3 1 - 5 1
Physical Location of the Swine Farm: a Si J C� o SI�2) e`_ LCS R L _
n r As a 'k 1
Owner(s) Name:
Mailing Address:
City, State, Zip Code: rto - -a n _ 0( a !3LV l -
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: A10-5g0-5a%L0 Email: 46�c rv,. nrl Cow
Current/New Integrator: �•• k-)x:��ro
Integrator Contact Name: ,.tzV : +r1 -e S r+
Mailing Address: �• S
City, State, Zip Code: 1 <- c- uJ L 3Q
Phone: % D - a 53 - 943 ail: _ \Su- e s in, r- 5 rn � �-fin--i.s--Nk
--
Owner's Signature
'�0/0 02 3
Date
We appreciate your cooperation. This information is required in accordance with G.S. 143-215.1011. 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: RAMESH.RAVELLA@,NCDENR.GOV
CISIR 03-25-2021