710006_Other_20200203

Animal Waste Management System Operator Designation Form
WPCSOCC
(CAC 15A 8F.0201
Facility/Farm Name:
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Pemlit#: &�7IDI0&
FacilitylD#:
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County:
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Operator In Charge (OIC)
Name:
First Middle
etc.
Cert Type / Number: 1 p0/� ) Work Phone: ( F/0 1 �� }?I
Signature: Date:
"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 OSF .0203 and failing to do so ran result in Disciplinary Actions by the Water
Pollution Contra! Systcm Operators Certification Commission."
Back-up Operator In Charge (Back-up OIC) (Optional)
Name:
,emote Last . ✓r. Sr. ere.
Cert Type / Number: Work Phone:
"I certify that I agree to my designation as Back-up Operator in Charge for the facility noted 1 understand and will abide by the rules and
regulations pertaining m the responsibilities set forth in t5A 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:
Phone #: ( 260 )) i Z ' 1/S11 Fax#: L20 1 j'h ) —e3G 3
Signature. JI e{ - 3—�?-�
(Owner or autha6aed•agenU Date.'
Mail, fax or entail the WPCSOCC, 1618 Man Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Email: certadadnna nedenr.aov
Mail orfax a copy to the Asheville
Fayetteville
appropriate Regional Office: 2090 US Hwy 70
225 Green St
Swannanoa 28778
Suitc 714
Fax: [phone]
Fayetteville 28301-5043
Phone: 828.296,4500
Fax: [phone]
Phuen; 910.433.3300
Washington
Wilmington
943 Washington Sq Mali
127 Cardinal Dr
Washington 27889
Wilmington 28405-2845
Fax: [phone]
Fax: [phone]
Phone: 252.946,6481
Phone: [phone]
Mooresville
Raleigh
610 E Center Ave
3800 Barrett Dr
Suite 301
Raleigh 27609
Mooresville 28115
Fax: [phone]
Fax: [phone]
Phone:919.79IA200
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
rRerarn a copy o) this jornl Jot tour• records)
0wited 05-2015