470003_OIC Designation Form_20240304

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 corpo ation, signature should be by a principal executive officer of corporation):
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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

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 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 S470003
2. Facility Name: Upchurch & Willis / C & M Farm
3. Permittee's Name (same as on the Waste Management Plan): Wayne Willis
4. Permittee's Mailing Address: 705 McDonald Ave
City: Raeford State: NC
Telephone Number: 910-818-7016 Ext. E-mail: willis875r aol.com
5. Facility's Physical Address: 460 Peck Ln
City: Raeford State: NC
6. County where Facility is located: Hoke
7. Farm Manager's Name (if different from Landowner): Wayne Willis
Zip: 28376-2347
Zip: 28376
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): Brian Michael Henderson Phone No.: c(I q, % l p ,3 a l 4 OIC #: 1011709
11. Lessee's Name (if there is not a Lessee, write "None"): jg6fq F_
12. Indicate animal operation type and number: '
Current Permit: Operations Type
Swine - Wean to Feeder
Operation Types:
Allowable Count
3,552
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