660030_OIC Designation Form_20240927

Animal Waste Management System Operator Designation Form
WPCSOCC,1618 Mail Service Center, Raleigh, NC 27699-1618
Facility/Farm Name: Farms 27-30
Permit #: AWG400000
Operator In Charge (OIC)
Name:
Facility ID#: 66 - 30 County: Northampton
First Middle l Last Jr, Sr, etc.
Cert Type / NumberAni M-al WQ Rtt q9 COZ ID Work Phone: (Z5 2- ) 510 " I S O
Signature: Date: Ci 124 20 2A
"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: LQrrV IQ 10 S i
First I Akddle Last i Jr, Sr, etc.
Cert Type /N i : QGq�I l Work Phone: ( 252 )Noo — 04g0
Signature: Date: _ 0, 2y i 202-q _
"I certify that ee to my designation a -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/PermitteeName: Murphy-Brown._LLC
Phone #: ( 910 ) 293-3434 Fax#: [
Signature: _-�
(Owner or authorized agent)
Email this form to: [e-mail]
Maii or fax to your
DEQ Regional Office (or
email to your contact)
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: 910AS6.0707
Phoen: 910.433.3300
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Date: 9/26/2024
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:919.791A200
Revised 11r2023
(Retain a copy of this form for your records)