710070_operator designation_20200102

Jan, 10. 2020 11:29AM
No.6199 P, 1/1
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name: 1 e,-T)
Permit #: �w S —) 10 0 —1 Facility ID#• �County: b ,0_r
Operator In Charge (OTC)
Name: K em &, ` k W � `' =B `t`n, C- , Y-,
First Mild% Lass Jr. & eic.
Cert Type / Number: �NW A � L 21 S . Work Phone:
Signature: Date:
"1 eercifY 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 15ANCAC OBI' _0203 and failing to do so can result in Disciplinary Actions by the -Water
Pollution Control System Operators Certification Commission."
Back-up Operator to Charge (Back-up OYC) (Optional)
Name
.Rrsr Middle fail Jr &I etc.
Cert Type / Number: Work Phone: ( )
Signature:
Date:
"1 certify that I agree to my designation as Hach -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/Permittee Name: v�, �() b1 M
Phone #: (q � O) ���' � 3 Faa�#: (9 1 0 ) a� J� ' % (L
Signature: - Date:
(Owner t
fficRwd agent) -
Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: 919.715,2726
original to: Email: certadminAued8nr.goy
Mail orfax a copy to the Asheville
Tayetteville
Mooresville
appropriate Regional Office: 2090 US Hwy 70
225 Ckeen St
610 E Center Ave
Swarmanoa 28778
Suite 714
Suite 301
Fat: 828.299.7043
Fayetboville 28301.5043
Mooresville 29115
Phone:[phone]
Fax:910.406,0707
Fax.-704.663.6040
Phoen:910,433.3300
Phone:[phone]
Washington
Wilmington
Winston-Salem
943 Washington S q Mall
127 Cardinal Dr
450 W. Hanes Mall Rd
Washington 27889
Wilmington 20405.2845
Winston-Salem 27105
Fax: [phone] ,.
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
(Retain a copy of this form for your records)
Revlsad a5 Za15
Raleigh
3800 Barrett Dr
Raleigh 27609
Farr: 919.571.4718
Phone:[phone]