310358_Other_20200203

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name:
P2
Permit #: AWv 3100 l7 Facility ID#: 31 3Sd' County: Pw,e
Operator In Charge (OIC)
Name:
Firs( Middle Last Jr. 5,% erc.
Cert Type / Number: &V 4 I d0V 3k) Work Phone: (o
Signature: '��j� 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 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 / Number:
Middle Lau Jr. Sr. erc.
Work Phone:
"9 certify that 1 agree to my designation as 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 ISA NCAC 08F .0203 and failing to do so can result in Disciplinary Actions by the
Weter Pollution Control System Operators Certification Commission."
Owner/Permittee Name:
Phone #: L Fax#; jg — 36 -3
Signature: Date: — 3 z 2
(Owner or auth genq
Nfait, fax or email We WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Email: certadminanedenr.aov
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 28301.5043
Phone: [phone]
Fax: 9I0.486.0707
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: [phone]
Mooresville
Raleigh
610 E Center Ave
3800 Barrett Dr
Suite 301
Raleigh 27609
Mooresville 28115
Fax: [phone]
Fax:[phone]
Phone:919,791,4200
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
rReruln a cola o/ this force for your records)