310358_Operator Designation_20200512

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name: n o � �C 5 t,
Permit#: � 1 D 3 Facility tD#: 3 County: �a, I 1�
Operator In Charge (01C)
Name:
First ` Aliddle V Last Jr. Sr, etc.
Cert Type / Number: Work Phone:( 7-52-
Signature: Date; el`2
"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:
First Middle Last _ Jr, Sr, etc.
Cert Type / Number: Work Phone: (_ 1
Signature:
Date:
"I 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 Operators Certification Commission."
Owner/Permittee Name: _
Phone #: �� ' �vU Fax#: (q1 O ) �jp2' q b b
Signature: Date: Z4�Zo�
(Owner or authorized agent)
Mail, fax or entail the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to. Email: certadmin0nedenr.eov
Mall 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: 828.296,4500
Fax, 910.486.0707
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: [phone]
Fax:[phone]
Phone:919.79IA200
Phone: 704,663,1699
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
(Retain a cope o/'this ror•ni forlour• records)
Revised 05-2015

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name: e U"Zjt or.
Permit#: v �� Facility FD#: 31 /7 -3 County: Ap �, �•
Operator In Charge (01C)
First ` AfFddte V Last Jr, Sr, etc.
Cert Type / Number: _ _ Work Phone: ( 7-5�
Signature: Date:
"r 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 1n Charge (Back-up OiC) (Optional)
Name:
First Middle Last _ Jr, Sr; etc.
Cert Type / Number: Work Phone. ( 1
Signattre:
Date:.
"I 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 ISA 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:---��ai� t.' %1'►°
Phone #: v U Fax#: l �� 0) ��2� � � b ZD
Signature: Date:
(Owner or authorized agent)
Mail, fax or entail the WPCSOCC, 1618 :Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Email: eertadminCa.nedenr&ov
Mail or fax a copy to tfte
appropriate Regional Office:
Revised 05-2015
Asheville
2090 US Hwy 70
Swannanoa 28779
Fax; 828.299.7043
Phone: 828.296,4500
Washington
943 Washington Sq Mall
Washington 27889
Fax:252,946.9215
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phoen; 910.433,3300
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: 910.796,7215
Mooresville
Raleigh
610 E Center Ave
3800 Barrett Dr
Suite 301
Raleigh 27609
Mooresville 28115
Fax: 919,571.4718
Fax:[phone]
Phone;919.79IA200
Phone; 704.663,1699
Winston-Salem
450 W. Hanes Mail Rd
Winston-Salem 27105
Fax. [phone]
Phone: [phone]
(Rerain a cops' O/ tNsfiorfli for your records)

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Faellity/Farm Name: '
Permit #: AIV 4' ^ Facility ID#: 3 , -�(t _ County: "
Operator In Charge (01C)
Firs( ' - btiddre V Last Jr. Sr etc.
Cert Type / Number: Work Phone: (1-S4 -/'
Signature: Date:
5 "2!!L22
"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 01C) (Optional)
Name:
Fka Middle Lash _ A, S7•, etc.
Cert Type / Number: Work Phone: ( }
Signature: Date:,
"I 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 ISA 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: _ bQat, & t ,r t b
Phone �#: 2� ' �v U Fax#. ( q4 o } ��2� � � tb IDSignattrre: Date: ' 2.4 - Z019
(Owner or authorized agent}
Mail, fax or entail the WPCSOCC, 1618 :Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Email: certadmin(afncdenr.>rov
Mail or fax a copy to the
appropriate Regional Office.
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax-, 828,299.7043
Phone: [phone]
Washington
943 Washington Sq Mail
Washington 27889
Fax., 252.946.9215
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phoen: 910.433,3300
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [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:919,791.4200
Phone: 704,663,1699
Winston-Salem
450 W. Hanes Malt Rd
Winston-Salem 27105
Fax, 336,776.9797
Phone: [phone]
(Aeruin a copy o fthis form for your records)
Revised 05-2015