310026_Other_20200203

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC I5A 8F .0201
Facility/Farm Name: /r1/1 Ef 1' /
Permit #: w—S 31 e il0.) k; Facility 1D9: 3 -1 County:
Operator In Charge (OIC)
Name: 9 P ti n 4 o �. tom[ J("� . -S
First Afiddle Lau Jr. Sr. etc.
Cert Type /Number: AL�A" Work Phone: 1 4f— J y 7
Signature: P*--Z,4 — .4 Date: —Z --j_W20
1 Certify that t agree to my designation as the Operator in Charge for the facility noted. 1 understand and will abide by the rules and regulations
pertaining to the responsibilities set forth in I5A 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:
Prrt ,Lliddlr Lav Jr. Sr, ac.
Cert Type / Number: Work Phone: ( 1
Signature: Date:
I certify that 1 agree to my designation as Back-up Operator in Charge for the facility noted- i understand and will abide by the Mies 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 Contort System Operaors Certification Commission."
Owner/Permittee Name:
Phone #: L ` 0 ) ,i` 2 -11Sli t Fax#: (_ `I/0 ) ,fI ) —6 jE 3
Signatuae:_.. -J lam`
(owner or auth gent)
Date: .2 — 3 z0
Mail, fax or entail the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Emas7: certadminna acdenr.eov
Mail orfax a copy to the Asheville
Fayetteville
appropriate Regional Office: 2090 US Hwy 70
225 Green St
Swannanoa 28778
Suite 714
Fax: [phone]
Fayetteville 28301-5043
Phone: [phone]
Fax: [phone]
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: [phone]
Mooresville
Raleigh
610 E Center Ave
3800 Barrett Dr
Suite 301
Raleigh 27609
Mooresville 28115
Fax: [phone]
Fax: [phone]
Phone:919.79lA200
Phone: [phone]
Winston-Salem
450 W. Hanes Mail Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
(Aeluia a copy ot this form for four records)
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