830008_Operator Designation Form_20200424

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Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 1SA SF.0201
i
FaciiltyfFarm Name: i•7 C 5 .r►"•5 L-LL
Permit#: 1Pt1Sr3 fOO S Faci1.ity 1Dri: 3 3 - r County: --co jtJ
Operator In Charge(O1C) ,/
Name:_� ( Y i'►r75�t!'�
First • Aild�tic Last Jr.Sr.etc.
Cert Type/Number: g'f /. Work Phone:(Z 2- ).S6 p-/Z)..tiO
Signature; w_ _ y Zy`247
Date:
"I certify that I agree to my designation at the Operator in Charge for the facility noted.I understand and will abide by the mles and regulations
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 System Operators Certificaton Commission."
Back-up Operator In Charge(Back-up OIC) (Optional)
Name:
First Middle Last Jr.Sr,ere !
Cert Type/Number: Work Phone:( )
Signature: Date:
"I certify that 1 agree to my designation as Back-up Operator in Charge for the facility noted.I understand and will abide by the rules and
rcgu:atioes pertaining to the responsibilities set forth in 1SA NCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the
Writer Pollution Control System Operators Certification Commission."
Owner/Peranittee Name: bQQ.0 ,. y 1u 1
Phone#: Z- ' 40 U Fax#:MI O t0 1 Lt.6 rj
Signature, Date: 14''2.' . 1o?.9
(Owner or author;zed agent)
Mail,fax oremail the WPCSOCC. 1618:Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone],
original to: JPmail;cortadmin(Oncdenr.gov
Mail or fax a copy to the AshevWe Fayetteville Raleigh
a3' MoorttsrlDc
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 5 Center Ave 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 Mooresville28115 Fax:[phone]
Phone:828.296,4500 Fax:[phone] Fax:[phone] Phone:[phone]
Phoen:910.433.3300 Phones 704.663.1699
Washington Wilmington Winston-Silent
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:252.9a6trf81 Phone:9[0.796.7215 Phone:[phone]
(Retain a copy of this form for your records)
Revised 05-2015