HomeMy WebLinkAbout480024_Other_20191221Jan 04 2000 09:39PM Rose Arne Farms 2529355801 page 1
Animal Waste Managcment System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Fise ty/Farm Name:
Permit#: �W P 'i8C90 Z�( Faeaity ID#: count3c—
Operator In Charge (OIC)
Name•
tern wrddte ._
Lef! Jr. Sr, de.
CcrtType / Number Work Phone: f stir ) 4 3 S S$C10
Signature. �~ Date:
"I catiiy that I agues to my desig "CM as the Ciporalor in Charge for the facility noted, I understand and will ahida by the rules and reguialk"
PCB to the respeosa Udes set for& in l SA NCAC 08F .0203 and Wing to do so can rmuh in Disciplinary Actions by the Water
Pollution Coultui Systsm Operators Catilkl ti0n Camsrosaion."
Back-up Operrter In Charge (Back-up OIC) (Optional)
Nam: 3'Atit'S S W 9A t, L
Fly ►A&k Lars—
Cert Type / Number: Work Phone: /ID f �?
Stgnatww , Date:_._..... / 2. 12 t !
"I eerdty that I agree 10 my d—Viatm as Hack -
up operator, is Charge for the ficiliry noted. I understand and wt71 abide by the rnks and
tegnlatiooa pertaiaiag to the r srbilities set forth in 15A NCAC 08F .0203 and failing to do so can Teak in Naoipl;nary Actions by the
Water PoUudon Cotrorol Syetem Operators Certification Commission,"
Owner/PermitteeName: our A yt
Phone #: ( $CZ ) NQ 7 -
Signature:.
(owner or i(4*&,vd gent)
Fa)r#: ! BI7 i '197 • zst(!
Date:
Mail, fax or easail the
drisiul to:
WPCSOCC, 1613 Maria Sarvim Center, RaletgN NC 27699.1619
Fa:r: 919.715.2726
dt'all or fax a copy to the
Asteville
Fayettevflie
Mooresville
Raleigh
+ppnepriatrRegionalOfflcti
2090 US Hwy 70
225 Green St
610 E Center Ave
3800 Barrett Dr
Sw mrama 28778
Suite 714
Suite 301
Raleigh 27609
Faso 828.299.7443
Move:82&296AS00
Fayetaeville 29301-5043
Mooresville 28115
Fax: 919571.4718
Fax:910A86.9707
Fax:764AO.6040
Phama:919.791.4209
Phaen:919.433.3300
Phone:704.663.1699
Wn"llton
Wilmingrns
Wisstonsalnu
943 Washington Sq Mall
127 Cardinal Dr
450 W. Hanes Mall Rd
Washington 27889
Wilmington 28405-2945
Winston-Salem 27105
Faa:252-946.9215
Fix:914.3502004
Fax.336.776.9797
P>bane: 257-946.6451
P10(ae: 910.796.7215
Ph— 336.776.9800
(Retain a copy of this farm for your records)
KeybCdOS•2015