640065_OIC Designation Form_20240320

State of North Carolina RECENM
Department of Environmental Quality
Division of Water Resources MAR 2 8 ZOZ4
Animal Waste Management Systems NC D£DlDWR
Request for Certification of Coverage Central OffiOe
Facility Currently covered by an Expiring Sate Non -Discharge General Permit
On September 30, 2024, the Noah Carolina State Non -Discharge General Permits for Animal Waste Management Systems will
expire. As required by these permits, facilities that have been issued Certificates of Coverage to operate under these State
Non -Discharge General Permits must apply for renewal g least 180 days prior m their expiration date. Therefore, all applications
mug be received by the Division of Water Resources by no later than April 3, 2024.
Please do not leave any question unanswered. Please verily all Information and make any nertcrary connections below.
Application must besigned and dated by the Pennine¢
1. Certificates Of Coverage Number: AWS640065
2. FacilityName: Middlesex Sow Farm
3. Perminee's Name (same n on the Wage Management Plan): Dennis Dowell Ramse
4. Permittee's Mailing Address: 634 Greenwillow Cir
City: Wendell Some: NC
Telephone Number: 919-365-3584Ern. E-mail: mbrams
insbellsouth.net
5.
Facilky's PhyslcalAddress: 7119 W NC 97
City: Middlesex Santa: NC
6.
County where Facility is located: hjisih
7.
Farm Managers Name (if different from Landowner):
g,
Farm Manager's telephone number (include area code):
9.
Integretors Name (ift here is rat an Integrator, write nN1one"):
10.
Operator Name(OIC):
Phone No.:
11.
Lessee's Name (if there is not a Lessee, write "None"):
n252-908-4996
y I Q ,y /QQIl 1
12.
Indicate animal operation type and number:
W
Current Permit: Operations Type
Allowable Count
Swine - Farrow to Wean
482
Operation Tvnes:
S.viu
cattle
Dry poultry
Wean to Finish
Dairy Calf
Non Laying Chickens
Weep to Fader
Dairy Heifer
Laying Chickens
Farrow to Finish
Milk Cow
Pullets
Fader a Finish
Dry Cow
Turkeys
Farrow to Wean
Beef Stocker Calf
Turkey Pullet
Farrow to Feeder
Beef Feeder
BnsdSmd
Beef Broad Cow
Wet Poulin
Gilts
Omer
Non Laying Pullet
Other
Layers
Zip: 27591-9588
Zip: 27557
OIC #: 17500
Other Tvnes
Horses - Horses
Horses - Other
Sheep- Sheep
sheep- Omer

NoWe: In accordance with NC General Statutes 143-215.6A and 143-215.6B, any person who knowingly makes any false
smtement, reprec uration, or mrtificarJon in any application may be subject to civil penalties up to $25,W0 per violation. (18
U.S.C. Section 1001 provides a punishment by a fine of not more than $10,000 or imprisonment of not more dean 5 years, or both
Four a similar offense.)
Print the Name of the PumitteefLandownedSigning Official and Sign below. (If multiple Landowners exist, all landowners
should sign. If dowmrr u1 a/corpontlou, swamm should be by a principal"ecadve offrm ooffthe corporation):
Ngnamme: Y1\1 Title:
Signatum: Date: C���_
Name (Print): _ _ Title:
Signature: _ Date: _.
Name (Print): _ Tale: _.
Signature: _. Date:
THE COMPI.E'TF.D APPLICATION SHOULD HE SENT TO THE FOLLOWING ADDRESS:
Umail: [e-mail]
NCDEQ-DWA
Animal Fending Operation Program
1636 Mail Service Center
Raleigh, North Carolina 2I699-1636

13. Wasm TYawmtlagom,Digestcmwd Wmm StaegePonda(WSP):(Fi1VVerifythefollowingioformafion.
htake all aecessmv continuous and provide missing date.)
Stmewrt
Name
Stmcmre'lype
(LagmoNDigeahr/
WSP)
Fslimaled
tear
Buih
Liner type
(Clry. syednda
Unknewv)
CaPe14
(Cable I")
Estimated
Surface Area
(Square Feet)
Design Freeboard
"ltedlice"
(Inches)
It
Lagoon
V111996
Fold. clq
153,123.00
27,950.00
19.00
coYERED 01
I.agmn
1/1A979
Full, clay
141,627.00
19,454.01
19.00
Submit one (1) ropy of the Certified Animal Waste Management Plan (CAWMP) with this completed and signed
application as required by NC General Statistics 143-215.1OC(d), either by waiting to the address below or sending it via
sound to the email address below.
The CAWMP muss include the following commissions'
1. The most recce Waste Utilization Plan (WUP), signed by the owner and a certified technical sneriallit, containing:
a. The method by which some; is applied in the disposal fields (e.g. Irrigation, injection, ear.)
b. Amap of way field used for land application (fur example: irrigation map)
c. The sail series present an every land application field
d The crops grown on every land application field
e. The Realistic Yield Expectation (RYE) for every crop shown in the W UP
f. The mardmm PAN to be applied to every ImW application field
g The waste application windows for every crop utilized in the WUP
In The required NACS Standard specifications
2. A site map/schematic
3. Emergency Action Plan
4. insect Control Checklist with chosen best management practices noted
5. Odor Control Checklist with chosen best management practices noted
6. Mortality Coo WI Checklist with selected method noted -Use the enclosed updated Mortality Control Checklist
7. Lagoodsmrage pond capacity documentation (design, calculations, etc.) Please be sure the above table is
accurate and complete. Also provide any site evaluations, weiland determinations, or hazard classifications that my be
applicable W yew ftaility.
9. operation and Maintenance Plan
If your CAWMP includes any components not shown on this list please include the additional component with yaw submittal.
(eg. composting, digesters, solids separators, sludge drying system, waste transfers, etc.)
I arms that this application has been reviewed by me and is accurate and complete to the best of my knowledge. I understood that,
if all rcquiwd parts of this application are fiat completed and that if all required supporting information and attachments are not
included, this application package will be ndumed on me as incomplete.