670047_OIC Designation Form_20240215

T-856 P0001 F-41
r()14
I-s ent of Environmental Quality
of Water Resources
Waste Management Systems
f'or Certification of Coverage
t an Expi b,%ring Sate Non -Discharge General Permit
l-
Diw-ge. Cieneral Permits for Animal Waste Management Systems will
On S epte m be r 3 01 20 24, it 1i NoArt lh ,A 1--, 1 t 'LN'on-L1sch
1.t ffiat have been issued Certificates of Coverage to operate under these State
expire. As required by these pt�rvnits- t
Non -Discharge General Permits in —lie. $11. expiration date. Therefore, all applicationsji.apl- 'I'V 'ii)r ?.*�%rieNyal at least 180 days prior to their
by nso laterthan April 3,2024.
mist be received by the Division c--f*W.,,:-t1-- � - . ,
Please do not leave atty Please verify all inforination and make atty necessary carrections below.
.yip plicationtnastire s"
orn . , . l. " r , rinittee.
I. Certificate N Oft'-'Over-l-Ag e , i I . # -4-/
Facility Name: S.-ij-dy
Plan): Ga!3! 3Dixon . Perma ittee's Nme (sattir; --
a,
4. Permittee's Malfingf;Adresi:
City: hicksonvi'lle. State, NC Zip:
Telephone Number: 91-0-34'7-
5. Facility's Physical Address: I w Hwy
�—Y
C'Ity: Jacksonville. State: NC-
Zip: 28540
6.
County where Facility is Jocattd.,
7.
Farm Manager's Name (if diffe-r-mv f-r;rr- n1owner):
"None"):
I
we
9.
Intogrator's Name (if there isz )-lot 4y lor, write
Alyr Phil w-11-1-1-4
-]>M,
1
()perator Name (.0 11i
'00-� 7
Phone 01C /J"e
11
Lessee's Narnt (Vffi "(: is nol!i
I I
A,
Indicate animal optrahon V% P
PerM A
Current A Type
Allowable Count
i-Fn- to Finish
7(
Operation Tyner -
swine
Dry Pault")
Other Type.
Wean to Finish
Non Laying Chickens
Horses -Horses
Wewi to Fee&-J-,
Laying Chickcris,
Horses -tither
farrow to Finisti
Sheep - Sheep
or to EU�LS�4
'Turkeys
Sheep - Other
marrow to We%an kul, 01 It'
Tarkey Pullet
Farrow to Feeder
Boar/Stud
Wet Poultry
Gilts
Non Laying Pullet
Other
Layers

Kb—
sjf- i. .1 —856 P0002 F-41
13. Waste Treatment La,,f-yi.-.�onls, Digester:ti aril Storg a e NJ ds VSSP); (Fill'Verify the, following information,
Make all necessary correc.tions ---itud i(k. nwss;ing data.)
Estimated
Date
Built
Liner 1'ype
(Clay, Synthetic,
Unknown)
Capacity
(ClIbic Feet)
Estimated
Estimated
Surface Area
Area Feet)
(Square Feet)
Design Freeboard
"kedfine"
(file -lies)
LAGOON I
L,--. g o ci n
8/3/1992
Full, clay
369.973.00
0. 00
56,000,00
19.00
Subwit one (1) copy of the Ctrtified A.Y.1'plal '� Iaste, Management Plan (CAWMP) with this completed and signed
application as re.qlaired 1)y NC Ge.qeral -Staftafes 143-215.10C(d), either by mailing to the address below or sending it viva
email to the email addre-�s below,
0 1
The CAWMP must inclukit, the fuilowhNq, ,-
1. The most recent Wznite- Utflization Pl;ui f WTJK signed by the owner and a certified technical SiDecialist., containing, -
a. The method by ".011ch Nvasts F, 11)"Tiled to the disposal fields (e.g. hTigation, injection, etc.)
b. A tilap of every field used for Is (--4 ndapp1i1?,ation (for example: irrigation map)
c. The soil series present on every land application field
d. The crops grown on every land toplication field
e, The Realistic Yield Expect.-ition for every crop shown in the WUP
-1
f. The maximum RAN to bV-appJieJt(- e.very land application field
g. The waste application windowsfor every crop utilized in the WUP
11. The required NRCS Standard
2. A site map/schematic
3- Emergency Action Plan
4, 111sect Control C-heckliii.A. with Qhos T I ' -le.s.t management practices noted
5. Odor Control Checklist with f--�Osc-rj best managernent practices noted
'hecklist v0th �i:.,!cc.(ed method noted.. Use the enclosed updated Mortality Control Checklist
C. Mortality Control SU
7. Lagoon/stora ' -ge, pond capacity doou r oental ion (design, calculations, etc.) Please be sure the above table is
accurate and complete. AN40 PrIC-1vide -,:inv site evahiattions, wetland determinations, or hazard classifications that may be
applicable to your facility.
S. Operation and Maintenanct, Pj,-t?1
If your (AWMP includeoc, any con-11porients rtk)( shown on this list, please. 'Include the additional components with your submittal.
A'
(e.g. composting, digesters, solids separ�)tc .Ir."., . � .,Iudge 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 fliat,
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 bre-tunv.!d tc) nie as '
e, Incomplete-

=� —1 �=t— �:!� v (_ �:; �C��'1-- _ t i �,� ��� ;_, 14 i ��,�. T-856 F���!OQ --
Note: In a cordanot, ti%Jfh Nvt:' `alittitrs 14,1�215.6A and 143-215,6B, ally person who knowingly makes any false
statement, representation, or ccrtifcalic i in any application may be subject to civil penalties up to $25,000 per violation. (18
U.&C. Section 1001 pruvldey a ponishnw nt b,a fine of not morb than $10,000 or imprisonment of not more than 5 gears, Orb' .s
for a similar offense.)
Print the. Name of the Pei, nii ,e/L��ni1f,,•�.� atnc f Signing Official and Sign below. (If multiple Landowners exist, all landowners
should sirin. It` Lancit>�� ne.t is a corpon(triron, isig �ati.irc �Wd be by a principal executive of�i tr of thz c;o oration):.
memo
Name (Print); � -�` A
Signature: - ,firS A•- __ ..�: `. ►� Date
�T
Name (Print),
Signature:
Name (Print):
Signature:
Title;
Date.
'title:
Date:
THB (70MPLh.-1-1 �} ,�P11L.I(-�ATIOX-SHO�.!LD BE SENT TO THE r4OLLOWING ADDRESS:
FAT13'IR: [e-mail]
Animal Fee -ding Operations Program
1636 Mall Service Center
Raleigh, North Carolina 27699-1636