430019_Operator Designation Form_20200420

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 1.5A 8F.0201
Facility/Farm Name: hL 4S dt ef M S iVG
'ermit#: Q,ItoS q30 D/q' Facility ID#' - f 9 County: i'rtf.
•
Operator j Charge(OIC)
Name: f ✓ c K,fe44 -
-irrt f Middle Last Jr,Sr,etc.
Cert Type/Num 1r: ,44 /009129 Work Phone: ( ) G5'S/ 7,7.2
Signature• Date: ff/v/o 20
"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."
'sack-up Operator In Charge(Back-up OIC) (Optional)
Name:
First Middle Last Jr,Sr,etc.
Cell 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 15A NCAC O8F.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name: sire,$ ///,4.5" �
Phone#: (7/ 870 Fax#: (g/e9) J/ 'e4.Z
`signature: Date: clA�02d
(Owner of authorized agent)
ljail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Email:certadminaincdenr.eov
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 28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:828.296,4500 Fax:[phone] Fax:[phone] Phone:[phone]
Phoen:910.433.3300 Phone;704.663.1699
Washington Wilmington Winston-Salem
943 Washington Sq Mail 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
• Fax:252.946,9215 Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
(Retain a cops'of this form for your records)
;ern..'d 05-2015