710098_OIC Designation Form_20240311

State of North Carolina
Department of Fnvironmental Quality
Division of Water Resources
Animal Waste Management Systems
Request for Certification of Coverage
Facility Currently covered by an Expiring Sate Non -Discharge General Permit
On September 30, 2024, the North 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 at least 180 days prior to their expiration date. Therefore, all applications
must be received by the Division of Water Resources by no later than April 3, 2024.
Please do not leave any question unanswered. Please verify all information and make any necessary corrections below -
Application must be signed and dated by the Permittee
1. Certificate Of Coverage Number: AWS710098
2. Facility game: Moore Farm
3. Permittee's Name (same as on the Waste Management Plan): Jason Emile Bordeaux
4. Permittee's Mailing Address: 9786 Shiloh Rd
City: Ivanhoe State: NC Zip: 28447
Telephone Number: 910-297-7739 Ext. E-mail: bordeauxie(@vahoo.com
5. Facilitv's Phvsical Address: 5056 Slocum Rd
City: Atkinson State: NC Zip: 28421
6. County where Facility is located: Pender
7, Farm Manager's Name (if different from Landowner):
8_ Farm Manager's telephone number (include area code):
9. Integrator's Name (if there is not an Integrator, write "None"): Murphy -Brown LLC
10. Operator Name (OIC): 11 Phone No.: OIC #;
I I . Lessee's Name (if there is of a Qe se .mvrite olrg'g:rue a A 910-21-7-7751 10 Q 9f)
12, Indicate animal operation type and number:
Current Permit: Operations Type
Swine - Wean to Feeder
Operation Types:
SWIAe
Wean to Finish
Wean to Feeder
Farrow to Finish
Feeder to Finish
Farrow to Wean
Farrow to Feeder
Boar/Stud
Gilts
Other
Cattle
Dairy Calf
Dairy Heifer
Milk Cow
Dry Cow
Beef Stocker Calf
Beef Feeder
Beef Broad Cow
Other
d 11--k6 rnimf
J,.cvv
Dry Poultry
OtherTypes
Non Laying Chickens
Horses - Horses
Laying Chickens
Horses - Other
Pullets
Sheep- Sheep
Turkeys
Sheep - Other
Turkey Pullet
WO Poulin
Non Laying Pullet
Lug ers

13. Waste Treatment Lagoons, Digesters and Waste Storage Ponds (WSP): (Fill/Verify the following information.
Make all necessary corrections and provide missing data.)
Structure
Name
Structure T}pe
(I.agm)nMigesterl
WSP)
Estimated
Dale
Buill
hiner'fype
(Clay, Synthetic.
Unknown)
Capacity
(Cubic Feet)
Estimated
Surface Area
(Square Feet)
Design Freeboard
"Redline"
(inches)
1
Lagoon
1/1/1994
Full. clay
423,877.00
60,025.00
19.50
Submit one (1) coPy of the Certified Animal NVasle Management Plan (CAWMP) with this completed and signed
application as required by NC General Statutes 143-215,IOC(d), either by mailing to the address below or sending it via
email to the email address belom.
The CAWMP must include the following components:
1. The most recent Waste Utilization Plan (WUP), signed by the owner and a certified technical specialist. containing:
a. The method by which waste is applied to the disposal fields (e.g, irrigation, injection, etc.)
b. A map of every field used for land application (for example: irrigation map)
c. The soil series present on 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 WUP
f. The maximum PAN to be applied to every land application field
g. The waste application windows for every crop utilized in the WUP
It. The required NRCS 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 Control Checklist with selected method noted - Use the enclosed updated Mortality Control Checklist
7. Lagoon/storage pond capacity documentation (design, calculations, etc.) Please be sure the above table is
accurate and complete. Also provide any site evaluations, wetland determinations, or hazard classifications that may be
applicable to your facility.
8. Operation and Maintenance Plan
If your CAWMP includes any components not shown on this list, please include the additional components with your submittal.
(e.g. composting, digesters, solids separators, sludge drying system, waste transfers, etc.)
I attest that this application has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that,
if all required parts of this application are not completed and that if all required supporting information and attachments are not
included, this application package will be returned to me as incomplete.

Note: in accordance with NC General Statutes 143-215,6A and 143-215.6B, any person who knowingly makes any false
statement, mprcscntation. or certification in any application may be subject to civil penalties up to $25.000 per violation. ( 18
U.S.C. Section 1001 provides a punishment by a fine of not more than S 10,000 or imprisonment of not more than 5 years, or both
for a similar offense.)
Print the Name of the Permiltee/Landowner/Signing Official and Sign below. (if multiple Landowners exist, all landowners
should sign. if Landowner is a corporation, signature should be by a principal executive officer of the corporation):
Name (Print): .0K
Signature:
Name (Print):
Signature: _
Name (Print):
Signature:
Title: 0 Wh G
Date: i 2
Title:
Date:
Title:
Date:
THE COMPLETED APPLICATION SHOULD BE SENT TO THE FOLLOWING ADDRESS:
E-mail: animal.operationsCa),deq.nc.gov
NCDEQ-DWR
Animal Feeding Operations Program
1636 hail Service Center
Raleigh, North Carolina 27699-1636