830008_Operator Designation Form_20190912

16 19.07:34p Barwick Agservices 9105900074 p.1
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC I5A 8F.0201
i
Facility/Farm Name: 13t-0 C srevoliLLZ /
Permit#: fTW� CO di r Facility 1D#: C.3 - sr County: sea //rem
Operator In Charge(OIC)/,,
Name: l ri+t1oy (S► e Na.ivi.,
First Middle Last Jr,Sr,etc.
Cert Type/Number: A-- DD Y 3eI Work Phone:( //0 ) 31--,r-6 2./ 7
Signature: 4- Date: 7-/2 —71
'2 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."
Back-up Operator In Charge(Back-up OIC) (Optional)
First Middle Lair Jr,Sr,etc.
Cert Type I Number: Work Phone:( )
Signature: Date:
"I certify that I agree to my designation as Back-up Opcnat:.r ir.Charge for the facility noted.I understand and will abide by the j.
rules and regulations pertaining to the responsibilities set f^rth in 15A NCAC 0BF.0203 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
•' � l4.-,
4wnerlPermrittee Name: 4 a! S
Phone#:( 4110 ) it - `- 5N-1 Fax#:( q//9) ei 2-6 36 3
Signature: _ Date: 9- /2 /9
•
Mail or fax to: WPCSOCC :s
1618 Mail Service Center
Raleigh,N.C.27699-1618
Fax:[phone]
(Retain a copy of this form for your records)
Revised L2007