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HomeMy WebLinkAbout820249_Operator Designation Form_20190523 Aug 0819, 10:32a RELEWD DEQI D WR AUG 0 8'2019 • Animal Waste Management System Operator Designation Form WPC SOCC WOOS NCAC 15A SF.0201 FAYE I IhVfLLFRFPANALOFFICE L cl £ M'G�rvwS T 1 . Facility/Farm Name: ' ea. J Permit#: PriA VA. - r ' Facility 1D#: 3'2 -2(1q County: -eet. 5�� Operator In Charge(OIC) Name: 6-tA7 8.41 !'r 44e,-- . First / Middle Last Jr,Sr,etc. • Cert.Type/Number: /� 16 ?�•- 2/4) Work Phone:( ) Signature:_ • ( 41Z'1 - Date:_ S—23 --/ "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(Back-up OIC) (Optional) , Name: First Middle Last Jr,Sr,etc. Cert Type/Number: Work Phone: ( ) Signature.- 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 pertainine 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:. j_ Phone#: (efid) Lc 3� 631 Fak#: ( ' ) . Signature: .�,J. (.s'l - - Date: S - 3 - l i (Owner ur thorizcd•&cnt) . Mail,fax or email the WPCSOCC. 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:919.715.2726 original to: Email:certadminAncdenr.gov 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 D: Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609 Fax:828.299.71143 Fayetteville 28301-5043 Mooresville 28115 Fax:919.571.4718 Phone:828.296.4500 Fax:910.486.0707 Fax:704.663.6040 Phone:919.791.4200 Phoen:910.433.3300 Phone:704.663.1699 . Washington Wilmington Winston-Salem 943 Washington Sq Mall 127 Cardinal Dr . 450 W.Hanes Mall Rd Washington 27889 Wilmington 28405-2845 Winston-Salem 27105 Fax:252.946.9215 Fax:910.350.2004 Fax:336.776.9797 . Phone:252.946.6481 Phone:910.796.7215 Phone:336.776.9800 . (Retain a copy of this form for your records) Revised 05-2015