310016_Operational Agreement_20190208

Feb, 8.2019 11:22AM
No.3062 P. 3
Animal Waste Management System OperatorDesignation Form
W)PCSOCC
NCAC 15A 8F .0201
Facility/Farin Name: {)YM 5 cc -
Permit #: 'P,wS %I 0 4, Facility TD#: 3 l 6 County: p
Operator In Charge (OIC)
Name: IgIjr4
tlrsr Middle Los(
Cert Type / Nlunber: AA I U a 6
Jr, &, e(c.
Work Phone: ( �/O ) 9 [RS-13 S ^ 7
"I certify that I agrec 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 081F .0203 and failing to do so can result in Disciplinary Actions by the Water
Pollution Control System Operators Certification Commission --
Back-up Operator Xu Charge (Bach -tip OIC) (Optional)
Name:
J9rsi Middle ' Last J'r, Sr, ere.
CertTZ pe1Number: Work phone:
Signature: Date:
"I certify tbat 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 081' .0203 and failing to do so can result in Disciphnarq Actions by the
Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name: IW r PSX I L l� /14 n
Phone #: 5 to a8 S - f 3 5_ _- Fax#:
(OUMOr
Date: /,2 -,R D -/,?
Mail, fox or email the 'WVPCSOCC 1618 Mail Service Center, Raleigh, NC 27699-1618 rag: 919.715.2126
original to: i tNm
� � is
Mail or fax a copy to the Asheville
,Fayetteville
appropriate JUgional 0fftce: 2090 US Hwy 70
225 Green St
Swannanoa28178
Suite 714
Fax:[phone]
FaycttnUe2830l-5043
Phone:828,296.4500
Fax:910.496,0707
Phoen: 910.433.3300
Washinpon
Wilmington
943 Washington Sq Mall
127 Cardinal Dr
Washington27889
Wilmington28405-2845
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
mo omville
610 B Center Avc
Suite 301
Mooresville 28115
Fax: [phone]
phone: [phone]
Raleigh
3800 Barrett)Dr
Raleigh 27609
Fax, 919.571.4718
Phoue:919.791.4200
Winston-Salem
450 W. Hans Mall Itd
Winston-5alem 27105
Fax: 336.776,9797
Phone:[phone] -
Ravised 05.2015
(Retain a copy of thisformfor your records)