400012_OIC Designation Form_20240226

State of North Carolina RECEWED
Department of Environmental Quality
Division of Water Resources MAR 01 2024
Animal Waste Management Systems NC DEO/DWR
Request for Certification of Coverage Central Office
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: AW S400012
2. FacilityName: Ham Town Farm
3. Permittee's Name (same as on the Waste Management Plan): Jerry Lynn Creech
4. Permittee's Mailing Address: 800 Creech Rd
City: Snow Hill State: NC Zip: 28580-8774
Telephone Number: 252-341-8769 Ext. E-mail: ilcenensi(a)aol.com
5. Facility's Physical Address: 1155 Hamtown Rd
City: Snow Hill State: NC Zip: 28580
6. County where Facility is located: Greene
7. Farm Manager's Name (if different from Landowner): Jerry Lynn Creech
8. Farm Manager's telephone number (include area code): 252-341-8769 Ext.
9. Integrator's Name (if there is not an Integrator, write 'None"):
10. Operator Name (OIC): rNe6eft+7-2reTE
,'a crLj l hn ^ Qme_c.J-N
11, Lessee's Name (if there is not a Lessee, write "None"):
12. Indicate animal operation type and number:
Current Permit: Operations Type
Swine - Wean to Finish
Operation Types:
Swine
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
Smithfield Hoe Production
Phone No.:-23-2-N-7:3M
aSa-344 - e169
Allowable Count
7,043
Dry Poultry
Non Laying Chickens
Laying Chickens
Pullets
Turkeys
Turkey Pullet
Wet Poultr-,
Non Laying Pullet
Layers
OIC #: 16508
987246 -
updated: Pb
Other Types
Horses - Horses
Horses - Other
Sheep -Sheep
Sheep - Other

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 Type
(Lagoon/Digester/
WSP)
Estimated
Date
Built
Liner Type
(Clay, Synthetic,
Unknown)
Capacity
(Cubic Feet)
Estimated
Surface Area
(Square Feet)
Design Freeboard
'Redline"
(Inches)
1
Lagoon
6/1/1994
Full, clay
1,172,094.00
138,600.00
19.00
Submit one (1) copy of the Certified Animal Waste Management Plan (CAWMP) with this completed and signed
application as required by NC General Statutes 143-215.1OC(d), either by mailing to the address below or sending it via
email to the email address below.
The CAWMP must include the following components:
/1. The most recent Waste Utilization Plan (WUP), signed b% the owner and a certified technical specialist, containing:
-S. 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)
fc. The soil series present on every land application field
✓d. The crops grown on every land application field
'tee. The Realistic Yield Expectation (RYE) for every crop shown in the WUP
`if. The maximum PAN to be applied to every land application field
✓g. The waste application windows for every crop utilized in the WUP
/h. The required NRCS Standard specifications
s12. A site map/schematic
-�3 Emergency Action Plan
Insect Control Checklist with chosen best management practices noted
--'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.
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, representation, 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 $10,000 or imprisonment of not more than 5 years, or both
for a similar offense.)
Print the Name of the Permittee/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): aeeC-4� Title: e:�7/f _
Signature: L Date: ;-/a2 X g"z-
Name (Print): (16 C ttleck
Signature:
Name (Print):
Signature:
Title: ( d ' P't". N �i
Date:
Title:
Date:
THE COMPLETED APPLICATION SHOULD BE SENT TO THE FOLLOWING ADDRESS:
E-mail: [e-mail]
NCDEQ-DWR
Animal Feeding Operations Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636