520015_OIC Designation Form_20240301

State of North Carolina
Department of Environmental Quality
Division of Water Resources
Animal Waste Management Systems
Request for Certification of Coverage
Facility Currently covered by an Expiring State 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 Pennits 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, make any necessary corrections, and
complete any blank fields belay. Application must be signer/ and dated by the Perrnittee.
1. Certificate Of Coverage Number: A WS 52 C 0 i 5
2. FacilityName: 2, GK 7 y nd of l I rowm
3. Permittee's Name (same as on the Waste Management Plan): 2 t Ghtxrd
4. Permittee's Mailing Address: 0 Pp Sox 15539
City: (Zi ch 1O111 C6
State: N
Telephone Number: CA 10 330
6777 �E,-,mail:( 5. Facility's Physical Address: 7 Zoi Did Corot4/ City: Trerl +U h State: N G
6. County where Facility is located:, Cone,5
7. Farm Manager's Name (if different from Pennittee):
Carl 1 yv,c�A� J
Zip: 2 6 51y'
Zip: 285Fs5
8. Farm Manager's telephone number (include area code): Q01per+ 6c)x 252— 2 81U '12L+2,
9. Integrator's Name (if there is not an Integrator, write "None"): `✓(Yl,+r\T1 e,14
10. Operator Name (OIC): Ro1�.rl Phone No.: y OIC
11. Lessee's Name (if there is not a Lessee, write "None")252 28L� L /1 jq 2'
12. Indicate animal operation type and number: 210bel* Cox
Current Permit:
Operations Type
Allowable Count
Operation Types:
rEej
352- D
Swine
Cattle
Dry Poultry
Other Types
Wean to Finish
Dairy Calf
Non Laying Chickens
Horses - Horses
Wean to Feeder
Dairy Heifer
Laying Chickens
Horses - Other
Farrow to Finish
Milk Cow
Pullets
Sheep- Sheep
Feeder to Finish
Dry Cow
Turkeys
Sheep - Other
Farrow to Wean
Beef Stocker Calf
Turkey Pullet
Farrow to Feeder
Beef Feeder
Boar/Stud
Beef Broad Cow
Wet Poultry
Gilts
Other
Non Laying Pullet
Other
Layers

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)
q
Submit one (1) copy of the Certified Animal Waste Management Plan (CAWMP) with this completed and
signed application as required by NC General Statutes 143-215.10C(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:
L 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
h. 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 143-215.613, 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 Pennittec/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): �j'({ r1��4) Title: jj t )r)&"'-
r
Signatur : Date: 3 Igq
Name (Print):
Signature:
Title:
Date:
Name (Print): ._
Title:
Signature: 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
If you have any questions regarding this application or the general permits, please call [phone].