310264_Operational Agreement_20190208

Feb. 8. 2019 11:23AM No. -3062 P. 9
.Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC ISA 9F .020I
Facilfty/FarmName: Ge-,) P Y\70-� A
Fact7ity TD#: u 1 -. County. _p H,
Operator In Charge (OIC)
Name:
.Last
Ceit Type / Number: ft W
�1 U
Jr. A. etc,
work phone: ( a kt 7 S 3
Date: - 0!
"1 certify. that I agree to my designation as the Operator in Charge forthc•facility noted. I understand and will abide by tE6 Tales and regulations -
pertainingto the responsibilitiea set forthin' 15ANCAC OBF .0203 and failing to do so can reaultinDisciplibatyActions by the Water
Pollution Control System Operators Ccrtificalion Commission,"
Back-up Operator U Charge (Back-up OIC) (Optional)
Name:
F6-sr Middle Lair A, &; etc.
Cent Type / Number: work Phone: ( )
Signature.-.
Date,
"I certify that I agree to my designation as B ack-up Operator in Charge for the facility noted. 7 understand and will abido by tie rules and
regulations pertaining to the responaibnitios sot forth iu l5A NCAC 08P .0203 and failing to do so can result in Disciplinary Actions by the
Water Pollurown Control System Operators Certification Commission."
11nn 1
Owner/Permittee Name: e L -6.,`
Phone #: (CO) ads- 1-3 S 1 Fax#:
Signature. Date:
(Owor agent)
Mail, fax or email the WPCSOCC, 1618 ,Mail Service Center, Raleigh, XC 27699-1618 Fag: 919,715,2726
original to: AmalLeertadmingnedenuoY
Mail orfax a copy to the Agheville
ldayettev1110
Mooresville
appropriate Regional 0,(f%e: - 20090 US Hvvy 70
225 Omen St
610 E Center Ave
Swannanoa 28778
Suite 714
Suite 301
Fax: [phone]
Fayetteville 28301-5043
Mooresville 28115
Phone:[phone]
Fax:[phone]
,Pax:704.663,6040
Phoew 910.433.3300
Phone: [phone]
Washington
' mMington
Wwaton-Salem
943 Washington S g Mail
127 CardinalDr
450 W. Banes Man Rd
Washington27889
Wiilmmgton28405-2845'
Wmston-Sa1cm27105
Fax:252.946,9219
FAY:910350,2004
Pax. 336.7769797
Phone: 252.9d6.6481
Vhotie:'910.796,7215
,Phone* 336.776.9806
(Retain a copy of this form for your records)
xcvLwa o52015
Raleigh
3 BOO Bauett Dr
Raleigh 27609
Fa'f: 91,9371.4718
Phone:919,791.4200