820303_Farm operator designation form_20211228

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Fae ity/Farm Name: L)'T &r rm
Permit #: OS EZ 0 303
Facility ID#:, - 30 3 County:
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DEC 2 8 2021
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Operator In Charge (OIC)
Name: 1,-)Ctiir��
First
Middle
Cert Type / Number: ! O t 0 3 t, $
Signature:
it►OJY
Last
Jr, Sr, etc.
Work Phone: ( 5 a. ) i5 - 61 lr?
%....--� �x...
Date: / Z - 2,
"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 OTC) (Optional)
Name:
Jr, Sr, etc.
First Middle
Cert Type / Number:
Signature:
Last
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: 1,N) rz,r r 1?..r, (Y1
Phone #: ( tea) at-1 5 -- 6 i IC -7
Signature:. --
(Owner or authorized agent)
Faxx#: (
Date: / Z - 2 - .�
Mail, fax or email the
original to:
Mail or fax a copy to the
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Email: certadmin(ncdenr.aov
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
'vFayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phoen: 910.433.3300
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Fax: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 05-2015
(Retain a copy of this forrn for your records)