830010_Operator Designation Form_20200924

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Animal Waste Managestlent System Operator Deal tio!
WPCSOCC
NCAC ISA 8F.0201
FadlitylFarm lame:
Facility lI}#: b,_ �County: S.
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Operator In Charge(OIC'1
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Name: L{ ter i1 a r ci f;ro;.8.. 1
Firm• :fiddle Lett
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Cert Type/Number:. 1, 5..15. " - '-�—
Work Phone:(.. w
Date: - 1� ~
-I ceriff that I agree Co my designation as the Operator in Charge for the facility noted.I understand and h
PeetaininS to the responsibilities set forth in BA NCAC 03F.0=03 and failing to do so.
Pollution Contnt Systemare eu it in I}�j:vilt abide by they and nguhaotts
Operatorsset in Commission."
03F.0: ptazY e.6%;;;,b•
t e Water
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Back-up Operator In Charge(Back-up 01C) (Opnonali
Name:
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Middle —
Let?
J. Sr e:r. -----_
Vrisi4 Cer,Type/Number:
Work?}tote:{ S
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•1 Certify that'I agree to my designation as 8aek.up Operator in Charge for the facility noted.I and
regulations pertaining to the responsibilities set forth in ISA NCAC 08F.0203 and Earl' to do so tar ten u will abide by the tyta and
Water Pollution Control System Operators Certification Comtnss:on." n re sull tt in I}i P
�P Araior+s by the
marry
Owner/Permittee Name: 1 Q O C' t 6-Y1
Phone : 10 j'`140 0 Fart f a1 O q --F tS rj
(Ownerorauthariy:dagenq Date: �"7 -]�-jam
Mail,fax or anrar7 the WPCSOCC, 1618:Wail Service Center, Raleigh,NC 27699-1618 Far.919.715.2726
original to: Email:eertadmi a ncdenr.gov
'fail or fax u copy to rue Athol* Fayetteville
appropriate Regional Office: 2090 US Hwy 70 ut Raleigh
225 Green St 610E Cite Ave Dr
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Swannaaoa 28778 Suite 714 Suite 101 Raleigh 27609
Fax:[phone] Fayetteville 2330I-SO43 Moorean c 28115 Fax:[phone]I8
Pbone:828.296.4500 Fax:[phone] Fax:[phone] Phonet9I9.791r4204
�' t' l Phoen:?IOA33.3320 nom 724.663.1499
Washington Wilmington WinstetnSalem
943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
Fax:[phone] Fat:910350.2004 Fax:[phone]
Phone:[phone] Phone:[phone] Phone [phone]
(Retain a copy of this form for your records)
Revise-3 o5-301S
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