310128_Other - OIC Designation Form_20200121

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name: z X, e G///, - 0A04 t ' LLe
Permit #: ld 148 Facility ID#: -3 6 - 1 County: SOZ114 �
Operator In Charge (OIC)
Name: ff �VAll A �/,O A4/ V1/�'rJLtOi✓.f�
First Middle Q Last Jr, Sr, etc.
Cert Type / Number: 8 �4 Work Phone:
Signature: Z;' / Date: �•�'�D'/7
" 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)
First Middle Last Jr, Sr, etc.
Cert Type / Number:
Signature:
Work Phone:
Date:
" I certify that I agree to my designation as Back-up Operator in Charge for the facility noted. 1 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."
Owner/Permittee Name: Zfg,e Z&
Phone #: (gy Fax#: ( )
Signature: 4Date
(6Ar or au<gXed agent)
Mail or fax to: WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]
(Retain a copy of this form for your records)
1114-19
Revised 8/2007