410013_ORC Designation and Rainbreaker Form_20220131

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DEVICES TO AUTOMATICALLY STOP IRRIGATION EVENTS
STATE GENERAL PERMITS
The State of North Carolina has issued State General Permits for animal facilities to operate in North Carolina. These
Permits meet both State and EPA requirements and provide coverage for the following types of facilities.
• AWG100000 - Swine Facilities
• AWG200000 - Cattle Facilities
• AWG300000 - Poultry Facilities with a liquid waste management system
You have recently been issued a Certificate of Coverage (COC) to operate your animal facility under one of these General
Permits.
Condition II.24 of each of these Permits reads as follows:
The Permittee shall:
a. install, operate, and maintain devices on all irrigation pumps/equipment designed to automatically stop irrigation
activities during precipitation; or
b. commit to provide for the presence of the O1C, a designated backup OIC, or a person under the supervision of an
OIC or designated backup OIC at all times during the land application of waste so that in of a precipitation
event, the irrigation activities will be stopped immediately. This commitment must be submitted in writing to the
Division on a form supplied by, or approved by, the Division. [G.S. § 90A-47
Installation of devices or submission of alternate documentation shall be completed within 12 months of the
issuance of the COC forMthis General Permit. The Permittee shall maintain such devices according to the
manufacturer's instructions and warranties. This Condition does not apply to manure spreaders or other equipment
pulled by manned vehicles. [15A NCAC 02T . 0108(b)J
Please check the box below that indicates your commitment to do one of the following.
❑ Within twelve (12) months of the effective date of a COC issued under this permit, I shall install, operate and maintain
devices on all irrigation pumps/equipment designed to automatically stop irrigation activities during precipitation.
This condition does not apply to manure spreaders or other equipment pulled by manned vehicles.
V I will commit to provide for the presence of the Operator in Charge (OIC), the designated backup OIC, or a person
under the supervision of an OIC or backup OIC at all times during the land application of waste.
"I certify under penalty of law that this document was prepared under my direction or supervision in accordance with a
system designed to assure that qualified personnel properly gather and evaluate the information submitted. Based on my
inquiry of the person or persons who manage the system, or those persons directly responsible for gathering the information,
the information submitted is, to the best of my knowledge and belief, true, accurate, and complete. I am aware that there are
significant penalties for submitting false information, including the possibility of fines and imprisonment for knowing
violations."
W/11TE de A2 7-)a12,1
Facility Name Permit Number
O ner/Permittee Name and Title (type or print)
fwd. /t00/3
6V, aiL i a 3
ature of Owner/Permittee Date
Signature of Operator in Charge (if different from Permittee) Date
DTASIE 1-21-2020

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name: W/ / 1, et Of t A t 2Lt
Permit #: 4 h f C 4 l (S!I1' Facility ID#: 1-2 I - 13 County: _) V(11 (d
Operator In Charge (OI/C7) `/
Name: /21 a' (ZL� d I AiA� /Tn/0 kid
First Middle Lair Jr, Sr, etc.
Cert Type / Number: /b O « `� 1 Work Phone: (3 et, ) 6 /.4
Signature: %/�6VLt� Gina- ..W
Date: / I
"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 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:
Phone #: (3'3 4-) t i /(
Signature:
.Ttf4' 1-16ph;i'J6
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zed agent)
Mail, fax or email the
original to:
Mail or fax a copy to the
appropriate Regional Office:
Fax#:(
)
Date: /—I -a .
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
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: [phone]
Phone: [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 form for your records)