820363_Operator Designation Form_20190131

0619, 11:48a p.6
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A SF.0201
' Facility/Farm Name: Lt.-4 ye t "''"�I L v 6
Permit#: ilI4S F- 1134/3 •Facility lD#: '2 i�-3 County: .5a ra•-•-,
Operator In Charge(OIC)
` l 4
Name: V i A C$�t I t a.Z 511
First Middle Last Jr.Sr,etc.
Cert Type/Number: 1 ' // 0 1 7O • Work Phone:( GI/D ).5'7 2-I I.2-Z
Signature: __�`- i t Date: f`3 f j f
"I certify that I agree to my designation as the gyrator 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-upOperator In (Back-upOIC)
p Charge (Optional)
Name:
First Middle Las: Jr.Sr,etc.
Cert Type/Number: Work Phone: ( 1
Signature: Date:
f%.`� "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 0SF.0203 and failing to do so can result in Disciplinary Actions by the
. Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name: 1�u {l e . -.5 LI-(' i'y n, j. ,r14„• �c r'�
t
Phone#:( C HO ) it erl• 351 3 Fax#:( 1/0• ) Cc - 0 /5
Signature: (9� -' gilt: e____ Date: ) .3 1-/ 9
(O,.+•ner or authorized age
Mail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
' original to: Email:certadmintdncdenr.eav
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 223 Green St 610 E Center Ave 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 2 83 0 1-5 043 Mooresville 28135 Fax:[phone]
Phone:[phone] Fax:[phone] Fax:704,663.6040 Phone:[phone]
• Phoen:910.433.3300 Phone:[phone]
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:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
(Retain a copy o!•this form for your records)
Ravi<_eil C.1-2015
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