830015_Operator Designation Form_20200924

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Animal Waste Management System Operator lesigati ion
WPCSOCC F°
? ;' ?{CAC 15A 8F.020I
Facility/Farm Name: 1D f b
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-_____ County: -5( e 11lu {
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Operator In Charge(01C1
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4 Narita: i.{ I c Ito{�1 i;1'c w`)
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Cert Type/N[mber: /, u D 9.Z 3 e .
Work Phone: - y„t� 7 _z
Signatrire Dom'^--� 2r
"I certify that I agree to:ay dosig;tation as the Operator in CiB;gc i!r the facility noted 1 up
• p�[ioing W the respoo»b:lints ect forth in 15A NCAC OSF.0203 understand and Poduri m COnoot S55t`n �+�failing to do so can res[+;t is °n t abide by[h_rules 3 eons
e stars Cott Contnis<_ion. Dlstip'tinary Aedonsby
s Back-up Operator In Charge(Hack-up O1C) (optional)
tt Nome:
Aria,lr
Las' Jr.Sr.ere
Cert Type/Number;
Work Phone:L )
. SYgratrn� --_
Date.
i "-ceitity that 7 age to my designstiot;as Back-up Operator in Ch rse roc the t t:ilirfnored.I noderstaad
F nSnlat:ona petzaiuing re the responsibilities se:forth in IS a NCA 08F.0203 and failing to do so can resin as Disciplinary
'� ' Water Pollution Canes;System 0 by Cat ruins and
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1'znittee Sane: � ' �►t IQ 1
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(Owner or a;.ttt-i:ed age.[ `` -- Date:A.:: _ �
Marl,fax or ezzzarl the,, original l to: W?CSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
( Email eertaduzin(a7ncdenr.gov
<a • rt ?mail orf¢ra co to tbre Asheville
x k copy Fayetteville
Raleigh
appro'FC Regional Office: 2090 US fiwy 70 225 Cr een St MooresvilleSwanionoa28778 Suite14 61 Suite 3a1 ite301 terA.ve RaltBareettDr
Fax:8I8 299.7043 Falat:eeilla 283O1-5043 2Tb09
Phone:828 Z96.4500 Fan:930.486.0707 c � �Fax:a 919.?9L4100
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Phoen:910.433.3300 Phones 704.663.1699
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Waehingtea Wilmington Winston-Salem
943 Washington Sq,Mall '.27 Cardinal Dr 430 W.Hanes Mali Rd
Washington 27889 Wilmington 28405-1845 Winston.galem27105
t .";' Fax:[phone] Fan:910,350.2004 Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
(Retain a cons'of this forinfor your records)
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