540141_Other_20200211

02/11/2020 10,06 (FAX) P.001/001
� 0,.,�4e 4 21t 1 /70
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name: J2 j a jCe_0-(.P=;m 14 h f 7 O 1
Permit #: AY�Ls.1�" 4D 1—�7` Facility ID#: - _ County: L-6i) D 1 i-
Operator In Charge (OTC)
Name: G la r'enCap L Sryiii h -
6rrat Mali! Last Jr, Sr, etc.
Cert Type / Number: i % e'LI Q Work Phone: (?= 52) 66 b { 1'' 6 5
Signature: (?Z t/ Z4-i U . Yy;� Date: .2 /t i ) Z O2 0
"I certify 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 15A NCAC 08F ,0203 and failing to do so can result in Disciplinary Actions by the Water
Pollution Control System Operators Certification Commission,"
Back-up Operator In Charge (Back-up OIC) (Optional)
Name: Daniel 1-K 11
Ftrst bite Lan Jr, Sr, era
Cert Type / Number: i/ no--rd z 1+w Work Phone: (P Sa 3 Zyg 5
Signature:— /wu.: e�./7//� Date: 2 II D 2 0
"1 certify that I agree to my designation as Back-up Operator in (urge for the facility noted. I understand and will abide by the rules and
regulations pertaining to the responsibilities set forth in 15A NCAC 08P ,0203 and failing to,do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
Owner/PermitteeName: _Camnu u E?nn'14 t
Phone #: 2GZ GsLQC) i I*(0 3 Fax#:-
Signature:Gt.f� GG ���I' �. Date: t Z a,2' O
(Owner or authorised agent)
Mall, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax. [phone]
original to: 'Email: certadminAimcderintov`
Mail orfax a copy to the Asheville
Fayetteville
appropriate Regional Q(%tce: 2090 US Hwy 70
225 Green St
Swannanoa 28778
Suite 714
Fax: 829.299,7043
Fayetteville 28301-5043
Phone:[phone]
Fax:[phone]
Phoen: 910.433,3300
Washington
Wilmington
943 Washington Sq Mall
127 Cardinal Dr
Washington 27899
Wilmington 28405-2845
Fax:[phone]
Fax:910,350.2004
Phone:[phone]
Phone:[phone]
Revised 05.2015
Mooresville
Raleigh
610 E Center Ave
3800 Barrett Dr
Suite 301
Raleigh 27609
MooresviIlc 28115
Fox: 919.57I.4718
Fix:704.663.6040
Phone:919.791,4200
Phone: [phone]
Winston-Salem
450 W. Hancs Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: 336,776.9800
(Retain a copy of this form for your records)