470026_Operator Designation Form_20200924

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Animal Waste Management System
{s ^n aerator Des on Form
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NCAC ISA 8F.0201
Faa7ityNarm Name: tAl ke. ie ;r 4-
Permit is:pi'.5 LI -1 Cyr ti Z Facility 11:34: - t,
county;
Operator In Charge(010
Name: LeL !�►c hai''c/ Frown J
First itiddre Lan
Jr.Sr ere.
Cert Type/Number:- /�'°9 3�
�� y5 '. Work Phone:{_c1/u ) 3>7 2<17
Signature: „ - - �4 4--.--
Date- -1
-I cer.A.that I agree to my designation as the Operator in Charge for the facil'
peromn6 to the responsibilities set fortis in isA NCAC OSF.0203 znd tilting w do noted.
a=demtin D will abide try the rules and regulations
Pout:don Control System Operators Cerditeation Commission. Disciplinary Ac ioasby the Water
Back-up Operator In Charge(Back-up Ol
0 (Optional)
•
Name:
First Afieldle
Last Ja Sr,er:.
Ceti Type/Number. Wont Phone:(
Signature: —
Date.
1 certify that 1 ate to try designatou as Back Operator in Charge for the facility cored 1 and
erstead end will``_ ra4ons Petiatnt[tg to responsibilities set forth in ISA NCAC 08F.0_03 and fhili to do so can elm and
r «arc Pollak=Control S n8
r
r� ?stag operators Certification Commission." Disciplinary Actions by the
Owner/Permittee Name: bQilii l.• a'1 lt(t
Phone 4: 1b .1Q1 140 O Fa : I C_ 3(D - q t4 6 b
Signc:ure: t��-- ``���_ Date � r
CO weer or artltuizcd agent
Z'7 ' -�
`" Mall,fax or email the WPCSOCC. 1618 Mail Service Center, Raleigh,NC 27699-1618 Fez:919.115.2126
{ r original to: Entail:eertadmianncdenr.rov
Mall orfaza copy to tke Asheville Fayetteville MoangvLle
Raleigh
aPPmo�Regional office; 2090 US Hwy 70 225 Green St 616 B Cenral Ave 3800 Barrett Dr
Stvamaaoe 28778 Seim 714 Suim 301 RNeigls27609
Farr 828.299.7043 Fayettety1Ee 28301.5043 bloanavi%n 28113 Fax:[phone]
Phaate:828.296.4500 Fax:[phone] Pam 704.663.6040 Plwna919.191A200
Phoen:910.4333300 Phone:[phone]
Washington Wilmington Winston-Salem
' 943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
r s P/aahiagcon 27889 Wilmington 2840.5-2845 Wi,u�-Salem 2710S
Fart 252.946.9215 Fax:[phone] $as1 336.776.9797
Phone;252946.6481 Phone:[phone] Phone:[phone]
(Retain a copy of this formfor your records)
Revised 05-2015
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2 20.04:29p Barwick Agservices 9105900074 p.4
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Animal Waste Management System Operator Designation Form A }: <r
WPCSOCC , 4,
NCAC ISA SF.0201
Facility/Farm Name: Sw r �'
Permit#: 1ld-Js 1 7 (,002 G Facility ID# 97 - '6 County: I1ô t e
Operator 10 Charge(OIC)
Name: 2ziel ilheY eC(" V lose r
MIKE IKE V Last Jr.Sr,arc.
Cel Type lNumber: g'/ / Work Phone:(ZS2- )Slap-11 #
Signature: tr^-- Dare: 7'2q 2)
s t "[certify that I agree to my designation as the Operator in Charge for the facility noted.'understand and will abide by the rules and regulations
7; pertaining to the responsibilities set forth in 1SA NCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the Water
Pollution Control Systom Operators Certification Commission.'
Back-up Operator In Charge(Back-up O1C) (Optional)
Name:
?H•xt Mridlr Last_ Jr.Sr,etc. j
Cert Type/Number: Work Phone:( 1 i
.
•' 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 falling to do so can result in Disciplinary Actions by the
Water Pollution Control System Opetators Certification Commission." 11
Owner/Permittee Name: 1)Q �' N'I'
Phone#,-•k ti- . I v Fax#:(tiE O) 61,2- el Lt 6 b
AlicAlvw
,. Signature: Date, 2'—Z4-2029
(Owner or authorized agent) '___
•
Mall,fax or email tire WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original CO: Email:certadminettcdenr.srov
Mail or fax a copy to the Asheville Fayetteville Mooresvllic 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:[phone] Fax:910,486.0707 Fax:[phone] Phone:[phone]
Phoen:9I0.433.3300 Phones 704.663.1699
Washington Wilmington Winston-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] Phone:336.776,9800
fftetuin a copy of this.forni for your records)
•
Revised US-tors '
„

'.720.07:04p Barwick Agsetvices 9105900074 p
• Animal Waste Management System Operator Designation Form `'
' WPCSOCC
NCAC ISA 8F.0201
Facility/Farm Name: 5 t4J", a f I-e,c
Permit#: Alt•S 47DO2le Facility ID#: 1/7.. 6 County: gOke.
• Y%te-
..
0
,'. . — Operator In Charge(OIC)
Name: `}(7.4i7 wi /11erh S eSSO/15
Hire Middle L,zt, Jr,Sr,etc.
Car:Type/Number: A/1:.«,;I .act3ie /GO 7.21/4/ Wo.k Phone:(it d ) 3 p S•'f c 7/
Signori:re: /-4 G1✓ ,& .y'
Date: 4/-6'0?0a4;
5 , -I certify Eh:i agree to my designation as the Operator in Charge for the facility noted.I understand and will abide by the reties and regulations
-�r paining to the responsibilities set fords in 15A NCAC 03F.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 O1C) (Optional)
Name:
Nisi Middle Last Jr Sr.err.
Ce:t Type;Number; Work Phone:(_
Signature: Date:
•
•'I certify that 1 agree to my designation as Back-up Operator in Charge forthe facility nosed.I understand and will abide by the rules and
regulations pertaining to the responsibilities set forth in ISA NCAC 087.0203 and failing to do so can result in Disciplinary Actions by the
Wale:Pollution Control System Operators Certification Commission."
Owner/Permittee Name: -DC4.. 'II//,,
Phone#: ( 7/1) a ), -1917V , Fax#:(y/O ) a)-' 49- cl
Signature: Date: V 8402 i)
..s, (Owner as
Mail,fax or email the VVPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: lanai!_eertadiedsa@acdcnr,zov
Mail or fax a copy to tire Asheville Fayetteville :Mooresville Raleigh
appropriate Regional Office: 2090 CIS Hwy 70 225 Green St 610 E Center Ave 3300 Barren Dr
Swannanoa 28778 Su:tc 714 Suite 301 Raleigh 27609
v. if Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:828.296,4500 Fax;910,486.0707 Fax:[phone] Phone:[phone]
Phoen;910.433.3300 Phone:[phone]
i Washington Wilmington Winston-Salem
943 Washington Sq Malt t 27 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmineton 28405-2845 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:252.946.648/ Phone:[phone] Phone:[phone]
(Retain a copy of this forme fir your records)
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