430019_Operator Designation Form_20191107

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Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 19A 8F .0201
Facility/Farm Name: V' e e 4 s i*,t y� k c.
Pemlit #. __A� 5 - 3 db I q Facility ID#: `i 3 I q County:
Operator TA Charge (01C)
Name:
First / Mrddrt t Last Jr, Sr, etc. Cert Type / Nt er: / 14 4133 Work Phone: (9l.j el .) D " 7 0OS 2
Signature: 0Date:
"I ceRify that I Qgree to My deli eti as the Operator in Charge for the facility noted.1. understand andwill abide by the rules and regulations
pertaining to the responsibilities set forth in 15A NCAC 08F .0203 and failing to do so caa result in Disciplimy Actions by the Water
Pollution cAntml System Operators Certification Commission-r
Back-up Operator In Charge (Back-up 01C) (Optimal)
Natne:
First bftddls Last Jr, Sr. 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 15A NCAC 68F .0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name:
Phone #: ZO D 7'4YV1 Fax#: ( /0) RIV y�16 Z
Signature.: pate. _. _. J41 /l - 7
(Owner or authorized agent) -
Mart, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
origin(rl to: Email: eertsdbft ticdenr.gov
Mail or fax a copy to the Asbevllle
Fayettevlue
appropriate Regfoeal Office: 2090 US Hwy 70
225 Breen St
Swatmanoa 28778
Suite 714
Fax: 82$.299.7043
Fa)tttevilte 28301-5043
Phone: 828.2%.4500
Fax- 910AN.0707
Photo: 910A33.3300
Washington
Wilmington
943 Washington Sq Mall
127 Cardinal Dr
Washington 27889
Wilmington 28405-2945
Fax:[phone]
frax:910350.2004
Phone-, 252.946.6481
Phonte 910.796.7215
moorasv111e
Raleigh
610 E Center Ave
3900 Barrett Dr
Suite 301
Raleigh 27609
Mooresville 28115
Fax., 919.571.4718
Fax:104A0.6040
Vhena:919.79IA200
Phone: [phone]"
Winste"alem
450 W. Hanes Mall Rd
Wind ;Salem 27105
Fax: [phone]
Pbolw- 336.776.9500
(Retain a copy of this form for your records)
Revised 05-2015