310683_Owner (Affiliation Change)_20160819

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name:
Permit # Facility ID#: County: AW
Operator In Charge (OIC)
Name:
4,9
First !diddle last l A Sr, etc.
Cert Type / Number. Al/%90 -,S9 Work Phone: d/9 ) �3�( - d
Signature: Date. 9'/ ff '/y
"I certify that I agree to my designation as the Operator in Charge for the facility noted. I understand and will abide by the rules
and regulations pertaining to the responsibilities set forth in 15A NCAC 08F .0203 and failing to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
Back-up Operator In Charge (Sack -up OIC) (Optional)
First Middle last Jr, Sr, em
Cert Type / Number.
Signature:,
Work Phone: ( )
Date:
"I certify that I agree to my designation as Back-up Operator in Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities set forth in 15A NCAC 08F .0203 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name: S.
Phone #: (�% 9) 2 3119 'zs�o Fax#: ( )
Signature: C.. Date: `19 ! b
I(oxner or authorized agent)
Mail or fax to: WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]
(Retain a copy of this form for your records)
RevLwd WOW

Notification of Change of Ownership
Animal Waste Management Facility
(Please type or print all information that does not require a signature)
In accordance with the requirements of 15A NCAC 2H .0217(a)(1)(14)(xii) this form is official notification to the Division of
Water Quality (DWQ) of the transfer of ownership of an Animal Waste Management Facility. This form must be submitted
to DWQ no later than 60 days following the transfer of ownership.
General Information:
Name of Farm: - I b
Previous Owner(s) Name:
New Owner(s) Name:
Mailing Address: 6ACA-6 %F /T.01UC
Farm Location: Latitude and Longitude: I
Please attach a copy of a county road map with location identified and describe
milepost, et&c.): fLc / ;>�yt Pi7i/t oS5/"
)
Operation Description:
Type of Swine No. ofAnimals
❑ Wean to Feeder
E3 Feeder to Finish /S 9/ 2
❑ Farrow to Wean
❑ Farrow to Feeder
❑ Farrow to Finish
❑ Gilts
❑ Boars
Type of Poultry
❑ Layer
❑ Pullets
No. ofAnimals
No: 3 I - b y-3
No: /�
No: ! l _ ?.3 2�5_e
County:
(Be specific: road names, directions,
Win
Type of Cattle No. ofAnimals
❑ Dairy
❑ Beef
Other Type of Livestock: Number ofAnimals:
Acreage Available for Application: . S'.3 Required Acreage:
Number of Lagoons / Storage Ponds : Total Capacity: 3 3 7 OCubic Feet (ft3)
Owner / Manager Agreement
I (we) verify that all the above information is correct and will be updated -upon changing. I (we) understand the operation and
maintenance procedures established in the Certified Animal Waste Management Plan (CAWMP) for the farm named above
and will implement these procedures. I (we) know that any modification or expansion to the existing design capacity of the
waste treatment and storage system or construction of new facilities will require a permit modification before the new animals
are stocked. I (we) understand that there must be no discharge of animal waste from the storage or application system to
surface waters of the state neither directly through a man-made conveyance or from a storm event less severe than the 25-year,
24-hour storm and there must not be run-off from the application of animal waste. I (we) understand that this facility may be
covered by a State Non -Discharge Permit or a NPDES Permit and completion of this form authorizes the Division of Water
Quality to issue the required permit to the new land owner.
Name of Previous Land Owner:_�� �✓iTt�-,oriS�S
Name of New Land
Date: S-19'1Z
Name of Manager(if different from owner):
Signature: Date:
Please sign and return this form to:
N. C. Division of Water Quality
Aquifer Protection Section
Animal Feeding Operations Unit
1636 Mail Service Center
Raleigh, NC 27699-1636
November 1, 2004