820253_Operator Designation Form_20191213

DEC 3. ''2019.
Animal Waste Management System Operator Designation Form r
WPCSOCC F/Y ' it{ QROS . E-FICA:
NCAC•15A 8F.0201 RECIONA l�.O
Facility/Farm Name: cN_ ,�� Wiz- 1 A.0-15 c i�.CL io. -
Permit#: 9 i, ".0 15 5Facility ID#: • g`� -a143 County: elf'`7's� `
•
Operator In Charge(OIC)
Name: f"1�,; a li` . 5/1,1t�1 .
First Middle qC� Last Jr Sr,etc.
Cert Type/Number: At.,,) A,-- ! `T 7) Work Phone: (�lJ )Sic— `�7 c l
Signature: )•"_"'�L Date: i 2/ /3//?
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."
•
Backup Operator In Charge(Back-up OIC) (Optional) .
Name: U.-c1t'.IC-, 1 ( r‘_\[ti Af41 P
First i�ddle Last Jr,Sr,etc. •
Cert Type/Number: A c q b ' Work Phone:(((() ) 3 f} S : D 1SS .
4------- . . • „Signature: A A .Date: t 3-/(3 ji q
"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: � `). F,,v- 1 f-iiC A l"� .
Phone#:.(9 ICE ) 3C-C k5 /9. Fax#:( ) . . .
• Signature: :}��/l f Date: ` /�3/�
' ----•'- -- - --- - -
- - (Owner or authonzed a- — .- - -- _,-- - ----'--
•X Mail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone] -. •
original to: (mail:certadmin a(?ncdenr.go. -
Mail or fax a copy to the Asheville ayetteville 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] : Phone:919.791:4200
` 11_ n:910.433.3300 Phone:[phone] •
.Washington Wilmingfou Winston-Salem •
943 Washington Sq Mall 127 Cardinal-Dr ' " 450 W.Hanes Mall Rd
Washington 27889-, Wilmington 28405-2845 Winston-Salem 27105
Fax:[phone] Fax:[phone]' Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone] .
•
(Retain a copy of this form for your records) .
Revised 05-2015