260003_CORRESPONDENCE_20201102

•
0.07:04p Barwick Agservices • 9105900074 p.1
tJ _ Animal Waste Management System Operator Designation Form
t, y': WPCSOCC
INCAC 15A SF.0201
Facility/Farm Name: ki- C 5:Kr
Permit �,,}
J�"5rn. Facility ID4: ‘.?('' - 3 . County Cci.-VA6€,/, �
-
Operator In Charge(OIC)
Name: tbsif �.=ct,Sn_n+
First I ,1fitdle n ruse Ir.Sr.err.
Cer,Type i Number: C 1 //r P O 3 70 Work Phone:( '//) ) 3 7 - .-qcys'
Signature:c _-i I'� y-211�0
Dare:
¢ "I certify the:i agree to my designation as the Operator in Charge fcr the facility noted.I understand and will abide by the rules and regulations
x . pertaining to the responsibilities set forth in 15A NCAC 08F.0203 and failing to do so car.result in Disciplinary Actions by the Water
Pollution Control System Operators Certification Commission."
• Back-up Operator In Charge(Back-up O1C) (Optional)
l' atne:
1 t: ,Vidole List
!r.So,etc
; . Cell Type/Number: Work Phone:
N., Signature:
,i+M "l certify that I agree to mydestg;alien as Back-up Operator in Charge for the lac:lity noted.I understand and will abide by the rules and
regulations pertaining to the reeponsibi`.ities set forth in ISA NCAC 0812.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Contro'System Operators Certification Commission" ,
OwnerjPermittee Name: - 4-(_ J W
G�
Phone 3: !�`�1 � L O�y� Fax'
( f`� ��7/
'ant• ' . Signature: C---" -r Date: 7-7 �y_)i0
(Gwner or auho izaa agent! `
Mail,fax or email the WPCSOCC, 1618 14ai1 Service Center, Raleigh.NC 27699-1618 Fax:[phone]
original to: Email:certadmin(asnedcnr.gov
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
': ' • appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 E Center Ave 3800 Barrett Dr
Swannanoa 2877R Suite 71+ St itc 301 Raleigh 27609
° ; st' Fax:[phone] Fayetteville 28301-5043 Mcoresville 28115 Fax:[phone]
Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone]
Ak". ''' ?hue:910.433.3300 Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wiimirgtan 28405-2345 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
(Retain a copy o)thi5 lo!'nt tort your records!
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