710044_Other_20200203

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
FacilitylFarm Name: 9h-f- �i --
I
Permit #: t /S7/ 0 0 `/ Y Facility ID#: W - YY County: >CPn ✓z
Operator In Charge (OIC)
Name: g r Li tz a n ti !-C.-e P4"_r,.9
First p,Afi'ddte Lust Jr. Sr. etc.
Cert Type / Number:
�)1/�rA- l90V �) Work Phone:(_ /�) '��-- 7
SIR72ature.'_ r*'Z' '� —�Zr Date.•
"I certify that I agree to my designation as Me Operator in Charge for the facility noted. I understand and will abide by the rules and regulations
pertaining to the reaponsibilities set forth in 15A NCAC OF .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 O1C) (Optional)
Name:
Cert Type / Number:
Last . Jr. Sr etc.
Work Phone:
Date:
"I certify that 1 agree to my designation w Back-up Operator in Charge for the facility noted. I understand and will abide by die rates 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:
Phone #: I Y/Q ) rt ) — L%iY Fax#: (. 20 ) r/' 3 —406 .3
Signature:_ -ee� —
(owner or5u att
Date:), — 3?02©
'Wail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Email: certathardaQuedillL.Lay
Mail or fax a copy to the Asheville
Fayetteville
appropriate Regional office. 2090 US Hwy 70
225 Green St
Swannanoa 28778
Suite 714
Fax: [phone]
Fayetteville 29301-5043
Phone: 828.296A500
Fax: [phone]
Phoen; 910,433.3300
Washington
Wilmington
943 Washington Sq Mall
127 Cardinal Dr
Washington 27889
Wilmington 28405-2845
Fax: 252.946,9215
Fax: 910.350,2004
Phone: [phone]
Phone: [phone]
Mooresville
Raleigh
610 E Center Ave
3800 Barrett Dr
Suite 301
Raleigh 27609
Mooresville 28115
Fax: 919.571,4718
Fax: [phone]
Phone:919.79lA200
Phone; 704.663.1699
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
(,tefain a cony o1 thIS iornl Ja• pour records)
k.V,sed a5-2015