710102_Operational Agreement_20190208

Feb. 8, 2019 11 : 23AM No, 3062 P. 6
Animal Waste Management Syste)x Operator Designation Form
WPCSOCC
NCA,C 15A SF,0201
Facflity/Farm Name: uj a
Permit#:A�W_S 1 0 y p Facility ID#: county: e
Operator In Charge(OZC)
Name:_R o.n gu G i T rl qr cL.M
first Mrd�s 1 os Jr,si;etc.
Cert Type/Num _ UJI4 h900369Work Phone:
r
Signature: Date:
"I certify that I agree to my designation ae the Operator in Cbarge for the facility noted.I understand and will abide by the Hiles end regulations
pertaining to the responsibilities set forth.in 15ANCAC 08F.0203 and failing to do so can result in biaciplinary Actions by the Water
Pollution Control System Operators Cetti legion Commission,"
Back up Operator In Charge(Back-up OYC)* (Optional)
Name:
First Middle Yasr Jr,5} etc,
Cert Type/Number: Work Phone:
Signature: Date:
`K cufLfY that I agree to my designation as Backup Operator is Charge for the fccnity noted 1 understand and will abide by the rules and
reguladobs pertaining to the responsibilities set forth in 15A NCAC 08F,0203 and failing to do so can result is.Disciplinary Actions by the'
Water Pollution Control System Operators Certification Commission."
Owner/PermitteeName: 1 l" -S L j► _�_6'�n
]Phone#;(r1 10) o�r3�- �.�5� Fax#:L!/0 6/�L
Signature: [�! Date:
(O'wner or auyuoriZed ai -
AM4 fax or ennail the 'WpCSOCC, 1618 Mall Service Centers, Raleigh,ETC 27699-1618 Fax:[phone]
original to: Em 'l: certadWnftedenneov
MaJ7 o►fax a copy to the Asheville- Fayetteville Mooresville Raleigh
appropt4ate Regional Office: 2090 US Hwy 70 225(been St 610 E Center Avre 3800 Barrett br
Swannanoa 28778 Suite 714 ' Suite 301 Raleigh 27609
Fax:[phone] Fayetteville28301-5043 Mooresville28115 Fax:919-ST1.4718
Phone:[phone] Fax;910.486.0707 Fax:[phone] Phobe:919.791.4200
Phoen:910.433.3300 Phone:[phone]
Washington w1bn1bgton 'Winston-3elem
943 Washington Sq Mall 127 CardmaX Dr 450 W_Banes Mall Rd
Washington 27889 Wilmington 28405 2845 Winston-Salem 21105
Fax:[phone] Faz.910350.2004 Fax:[phone]
Phone.,252.946.6481 Phone:[phone] Phone:336,716.9806
(Retain a copy of thisfor7nfor your records)
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