310863_Integrator Registration_20230621

Change of Swine Integrator Registration Form
Farm Name: i i n 7 ro► --,A= ` (�; rmak
Facility Number:
Physical Location of the Swine Farm: O r+ c
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Owner(s) Name: �V-D-A-"
Mailing Address: x 4 ;�, S
City, State, Zip Code: _-Vo.:� s n cn ClC.- -113 1
Grower(s) Name if different than Owner:
Mailing Address:
City, State, Zip Code:
Phone: G1 b - Ci34S- D 1'�
Email:
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Current/New Integrator:
Integrator Contact Name: -e % km r-,
Mailing Address: �• C6- S L
City, State, Zip Code: Lk.� ,-•- C r YZ C— 3 -
Phone: %Ip-aS3-343 mail: kw Q-S-br,Cr 5 �''�' ��� • Lo m
Owner's Signature
1-41 t a3
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: [e-mail]
CISIR 03-25-2021