710017_Other_20200203

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name:
Permit #: /— w 5 -7) eA
/ -i Facility ID#:
County:
Operator In Charge (OIC)
Name:
Firs( Middle Las( Jr. Sr. are.
Cert Type/ Number: Work Phone: (/�) 3m,� 7
Signature: Date: -"Z
" 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:
Cert Type /
Middle Last _ Jr. Sr, are.
Work Phone:
"I certify that I agree to my designation m Back-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 I SA NCAC 087 .0203 and fairing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name:
Phone # e d'4 z ' ySlf l Fax#: L610 1 0) —e36 3
Stgnature:__.,A Date: ' 3 —2-02�
(Ownerorauth ent)
Mail, fax or entail the WPCSOCC, 1618 Mail Service Center. Raleigh, SIC 27699-1618 Fax: [phone]
original to: Email: certadminCa)aedenr.aov
Mail or fax a copy to the Asheville
Fayetteville
appropriate Regional Office. 2090 US Hwy 70
225 Green St
Swannanoa 28779
Suite 714
Fax: 828.Z99.7043
Fayetteville 28301-5043
Phone: 828.2%.4500
Fax: 910,486.0707
Phoen: 910.433.3300
Washington
Wilmington
943 Washington Sq Mall
127 Cardinal Dr
Washington 27889
Wilmington 28405-2845
Fax: [phone]
Fax: [phone]
Phone: [phone]
Phone: 910.7%.7215
Mooresville
Raleigh
610 E Center Ave
3800 Barrett Dr
Suite 301
Raleigh 27609
Mooresville 281 IS
Fax: 919.571.C18
Fax: [phone]
Phone:919.791A200
Phone: 704.663,1699
Winston-Salem
450 W. Hanes Mail Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
(Aerata a copy or rhts I M (or your reeordsl
Imsed OS-?eti