250019_Other_20191224

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 817.0201
Facility/Farm Name: U_&) t;-1 .1_1
v
Permit #: 4�jS 2 Facility ID#: I"I County: llji"eW�
Operator In Charge (OIC)
Name:
First ,Middle— Last ---I /�Jr, Sr, etc. /� �/
Cert Type / Number: �[/1/ 1�47d Work Phone: a 1p )J ) '` clq : Va y
Signature: G',C_ �� _�� _ Date: (L �2 r
" 1 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 (Back-up O1C) (Optional)
Name:
First
Cert Type / Number:
Signature:
Middle Last Jr, Sr, etc.
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:
VMs �Lc
Phone #: I—eqK Fax#: ( ) / /
Signature: Date: U2
(owner or authorized agent)
Mail, fax or email
original to:
NC 27699-1618 Fax: [phone]
Mail or fax a copy to the Asheville
Fayetteville
Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70
225 Green St
610 E Center Ave 3800 Barrett Dr
Swannanoa 28778
Suite 714
Suite 301 Raleigh 27609
Fax: [phone]
Fayetteville 28301-5043
Mooresville 28115 Fax: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone](0„
Phoen:910.433.3300
'VE�I�q��d10
Phone:704.66 t"'
W *_0=
Wilmington
Winston-Salem
943 Washington 90*W
127 Cardinal Dr
450 W. Hanes Mall RDEC 3 O 2019
Washington 27
Wilmington 28405-2845
Winston-Salem 27105
Fax: [phone]
` " '•
Fax: [phone]
Fax: [phone] ter Duality Regional
�
Phone: [phone]
Phone: [phone]
Aerations Section
Washington Renional Office
(Retain a copy of this form for your records)
Revised 05-2015