470001_Operator Designation Form_20200924

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2020 2020-09-23 095335.jpg
System
Animal Waste Management
:, Operator Designation Form
WPCSOCC
NCAC ISA 8P.0201
Facility/Farm Name: >)Y(,'-s 16'�e,It,
Pe:tntit# , , y 7v)l: / - _____
Facility!DP: Y.L._
•," Operator In Charge(OICI
r
Name: L{1-'-- e!c11a.fc' bro;.,in
•
First ',fiddle is r
Jr.sr:ex.
Cert Type/Number:. /. U!�9 3°
�" Work Phone .�Iv 7 -Zy7 -
Signature ..,,-__,e_. -
Date: -2 2tJ
. Pc4 -"I certify that I agree to my designation as the Operator in Charge for the facility=red.1 understand and aia abide by the tales ar d lauant.
;,
iningto the responsrltrlides set forth in ISA NCAC OIF.0203 ar-d failing to do an can result in Disci inary
Pollution Control System 0~ierators Certification Commis
Sion.' P1 Actions by the Wez'e:Mu
.,, i
Back-up Operator In Charge(Back-up O1C) (Optional;
Name:
First Aida Lost --—
Jr.Sr.art. --
Cart Type/Number.
__ Work Phone:( }
3Ygrarure:
Date:
: ; Back-up"leettirytha:ltomydaigttztioaas
., tf' agree
: ,t relations Opmator in Charge for the facility noted.1 enderttttad and will abide by them and
a "i pertaining to the responsibilities set fb-th in ISANCA�_03F.(203 and tilling
R Ater Pollution Cotrsol System OperatorsCer icaaee Commission. to do so can ruult in biscipliaary Actions by the
' Owner/Permittee Name: NU ',,_f_ 1 tiFY1
Phone r: 10 7,- O U Fax*:(2 1 O, pZ- ei iS
Signature:
(Onx:r or authorized cgentj�-.-1` Dare: 'Z+ ���
Mail,far or email the WPCSOCC, 1618:Vial!Service Center, Raleigh,NC 27699_1618 Fax:[phone]
original to: Entail:certadminOncdeur.gov
Matt or/ax a copy to rite Asheville Fayetteville MoarssvIlle
Rakish
appropriate Regional Office: 2090(IS Hwy 70 225 Green Si 610 E Canter Ave 3806 Dr
Swannanoa 28778 Suite 714 Suite301 Raleigh27609
Fax:[phone] Fayetteville 28301-5043 Moa nav1l1c 28115 Fix;919.571.4718
Phone:[phone] Fax:910.48b.0707 Fax:[phone] Peone:919.79142ee
Paoen:910.433.3300 Photo 704.663.1699
Washington Wilmington Winston-Salem
943 Washington S Mall 127 Cardinal Dr
. �' St 4 450 W.Hanes Mail Rti
:1 Washington 27889 Wilmington 28405-2845 Winston-Stnerrt 27I05
Fax:[phone] Fax:[phone] Fax:[phone]
•
Phone:[phone] Phone:)10.796:721S Phone:33i-776.9800
(Retail:a copy aphis form for your recordi)
Reviled 05.3015
hips:/lmail.google.com/mail1u10/#inbox,Fhlfcgxw•JXxvNphjrLsckJchRgLZBh0Kg?projscto-l8messagePattld=0.1 in

-y 12 20 04 29p Barwick Agservices 9105900074 P.5
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC I SA BF.0201
Facility/Farm Name: /l O9 S if l'a T`t
( y �j
Permit#: 14-1 /11)0 0 f Facility[D#: 7 - / County: "hie
Operator In Charge((NC) •
Name: ?t,612 449e4i Y Ais,r\
First Middle Last Jr.Sr.etc.
Cert Type/Number: r Work Phone:(Z 1- 1t.:/r0
Signature.' y-�- Date: 9Z1 2v
•'1 certify that I agree to my designation as the Operator in Charge far the facility noted.I understand andwill abide by the rules and regulations
p:mining to the responsibilities set forth in 15A NCAC 08F.0203 and failing to do so can result it Disciplinary Actions by.be Water
Pollution Control System Operators Certification Commission,"
Back-up Operator In Charge(Back-up(MC) (Optional)
Name:
First Last_ Jr,Sr.etc
CC:t Type/Number: Work Phone:( ) J
Signature;
Date:
"I cctify that 1 agree to my designation as Back-up Operator in Charge for the facility noted.I understand ana will abide by the rule,and
:eytr rations pertaining to the responsibilities set forth in 1SA NCAC 08F.0203 and falling to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
� ` tipsy)
Owner/Permittec Name: t t.)Q an C,' 1'1 t to r
Phone#:"t • ? ) - 41)1D Fax#:(q10) g b b
Allipkor
Signature,. Date: Li''2-4'??02
(Owner or authorized agent)
Mall,fax or entail the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Email:certadminlil tredenr.Qov }
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 22S Green St.ff 610&Center Ave 3800 Barrett Dr
Swennenoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 28301.5043 Mooresville 28115 Fax:[phone]
Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone]
Phoeat 910.433.3300 Phones 704.663.1699
Washington Wilmington Whsataet-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmington 28405.2845 Winston-Salem 27105
Fax:[phone] • Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phones 336.776.5800
(Retain a cope nl:lsis form for)cur records)
Revise)05-201S

Itp.r.-
2720.07:04p BarvvickAgservices 9105900074 ' p.3
Animal Waste Management System Operator Designation Form
WPCSOCC
_i NCAC 1SA 8F.0201 •
Facility/Farm Name: l:l 5 item 141
Permittl: Alt)5 li700D I Faciiity ;DY: 17 - / County: HOk'e
„�' - Operator In Charge(OIC)
Name: Ja/t W.'V,/J l G/-1 C'S.S0/15
First Atiddle Last Jr.Sr.en.
Cert Type I Number: /JA:fin;f t✓jjte /GO 5 eiy Work Phone:( c7-/0 ) 3 KS--/q7 7,/
Signature. G✓ ,&jspor7.0----' Date: 4/-6—c?O,)O
"I certify that 1 agree to my designation as the Operator in Charge fort:te facility noted."understand and will abide by the rates and regulations
pc taini.!' g to the responsibilities set forth in 15A NCAC 03F.0203 and failing to zo so can result in Disciplinary Actions by the Water
.aurora Control System Operators Certification Commission...
Back-up Operator In Charge(Back-up OIC) (Optional)
Name:
rn•st .diddle Last - J.S. etc.
Cert Type/Number: _ Work Phone:( )
r-: Signatltre- ijate
lit
` "I certify that I agree to try designation as Back-up Operator in C atge for the facility noted.I understand and will abide by the rates and
• regulations pertaining to the responsibilities set forth in 15A Ny^AC 38F.0233 and failing to do so can result in Disciplinary Actions by the
Water Polkdon Control System Operators Certification Commissicn."
. OwneriPermittee Name: Del",- k �/
Phone 4: tN 1 6 )- -Inv r Fax4:(f/O } a..)-— ‘1y [i
.r . ,
'. :;t Signature: V
',4i#t (Owner. t wiz sg Date: ��0
Mail,fax or email the WPCSOCC, 1618:Mail Service Center, Raleigh,NC 27699-2618 Fax [phone]
. original to: Email.:certayimjgGoaneden r.gov
Mail or fax a copy to rite Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 2.25 Green Si 610 E Center Ave 3800 Barrett Dr
Swann woe 28778 Sui:c 714 Suitt 301 Raleigh 27609
Fax:[phone] aye:teviile 2330:-5043 MooresvJie 28115 Fax:[phone]
, Phone:[phone] Fax:930.486,0707 Fax:704,663.6040 Phone:919.791A200,
>'.4: "hoen:910.433,3300 Phone:[phone]
,
Washington Wilmington Winston-Salem
, 943 Washington Sq Mall 127 Cardinal Dr
450 W.Rases Mall Rd
Washington 27889 Wilmington 28405-2845 Winston-Sakm 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phones 336.776.9800
(Retain a cost r;tilts Orin jor your records)
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