310672_OIC Designation Form_20240325

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name: Austin Farms #1 & #2
AWS310672 31 _ 672 County:Duplirt
Permit #: Facility ID#:
Operator In Charge (OIC)
Name:
GregoryP. Moore
First Middle Last Jr. Sr, etc.
910 290 - 0033
Cert Type /Number.. AWA 18113 Work Phone.. ("9- _ �
14 bid=
Signature:
Date:
« Operator in Charge for the facility noted. I understand and will abide by the rules
I certify that I agree to my designation as the Ope g and regulations pertaining to the responsibilities set forth in 15A NCAC 0817.0203 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)
MAT i Ci4 'p N 1 I -LIP 01001T
First Middle Last Jr, Sr, etc.
Work Phone: q�� Z7► — U+ S
Cert Type / Number:loog.t-
YP
Signature:
Date:
3 - Z 4 - Z A-j
"I certify that I a r to my designation as Back-up (Operator in Charge for the facility noted. I understand and will abide by the
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rules and regulati s 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:
Beth S. Moore on behalf of Austin Farms, Inc.
Phone #.
910 ) 285 - 3896 Fax#:
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Signature: Date:
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(Owner or authorized agent)
Mail or fax to: WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]
(Retain a copy of this form for your records)
Revised 8/2007