310042_OIC Designation_20220105

Facility/Farm Name:
Permit #:
Animal Waste Management System Operator Designation Form
W PCSOCC
NCAC 15A 8F .0201
064! 04d I,ro'l isrs
r4-wS 3 (o o N ot
Facility ID#: 3 - OO"I County:
Qt�,Plin
Operator In Charge (OIC)
Name: TO h4 p t'cN t
First
6-6“-Acr
Atiddle Lair
Cert Type / Number: A W 4
Signature:
ao3
Jr, Sr, at 1 1
Work Phone: ( )( Doi 9 tl`
Dale: 1 /S /01
"1 certify that 1 a to my designation as the Operator in Charge for the facility noted. I understand and will abide by the rules and regulations
pertaining to responsibilities set forth in 15A NCAC 08F ,0203 and failing to do so can result in Disciplinary Actions by the Water
Pollution Ck. trot 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 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/Permirtee Name:
Phone #: (4/Q) 0) G 'f t 0
Fax#: ( )
Signature:
(Owner or authonzed agent)
Date:
1/5-/otiol
Mail, fax or email the
original to:
.hail or fax a copy to the
appropriate Regional Office:
tad 05-2015
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Email: certadmin n nedenr.t;ov
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phoen: 910.433.3300
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax; 910.350.2004
Phone: [phone]
Fax: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Banes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
(Retain n copy of this /item Jar your records)
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]