310143_Other_20200203

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/FarmName:< %ta,ef.t I
Permit #: AwIS 316 0) 4 3 Facility 1D#: 31 -L� County: 1) wP �r•
Operator In Charge (OIC)
Name: R r G rt do .
Ftrst
Lam Jr. Sr. etc.
Cert Type I Number: &V A- ) 000Lf3ki Work Phone: (_ F« 4 1 '7
Signature: /;/—�Z, �r�� �— Date: �/z'w 2 o
"I certify that 1 agree to my designation as dte 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 O1C) (Opitonall
Name:
Ff,:rt
Cert Type / Number:
Signature:
Lrsl A. 5,, etc.
Work Phone:
Date:
" 1 certify that I 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 15A NCAC 08F .0203 and Failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operaom Certification Commission."
Owner/Perinittee Name:
Phone #: (a ) ,f +: � -'fS 1(Fax#r: L10 ) fk ) —6 36 -3
Signature: _ Z
(Owner or auth gent)
Date: _ , — 3 z�
Mail, fax or entail the WPCSOCC, 1618 Mail Service Center. Raleigh, NC 27699-1618 Fax: [phone]
original to: Email: certadminQucdamr ov
Mail orftrx a copy to the Asheville
Fayetteville
appropriate Regional Office: 2090 ❑S Hwy 70
225 Green St
Swamanoa 2877E
Suite 714
Fax: 828,299,7043
Fayetteville 28301-5043
Phone: [phone]
Fax: [phone]
Photo; 910.433.3300
Washington
Wilmington
943 Washington Sq Mail
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:[phone]
Phone: 704.663,I699
Winston-Salem
450 W, Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: 336,776.9800
'Ret(4lll a cony o/this f )'nl for your records)
1 e 1ld 05-20I s