830010_Operator Designation Form_20200408

'.7 20.07:04p Bar,,,ich Agservices 9105900074 p.1
Animal Waste Management System Operator Designation Form
w'PCSOCC
NCAC 15A 8F.0201
'181
-�,�;; Facility/Farm name:
,., „ex
Y.
Permit#: “3 jb1 i) Facility ID#: 83 • /© _County: 5110 rAr.1
- Operator In Charge(OIC)
Nzme: `-/Qi1+T WJ /!14rh .5C'SSo,1S
y .`,:si Afiddle Lest Jr.3,.etc.
`, ' Cert Type i Number: An:- •4.7Jtt /OO% 41y 1hrork Phone:( it el 7, 3 O S -)°7 7/
Sigr:arura. � 4✓ , ,04 r�71 ey i Date: 11^6-070)0
"I certify that I agree to my designation as the Operator in Charge for the faci,ity noted.;understand and will abide by the rules and regulations
pertaining to the responsiyiiiies set forth is ISA NCAC 03F.0203 and failing to do so can result in Disciplinary Actions by the Water
Pollution Control Systcrn Operators Certification Commission."
`',; Back-up Operator In Charge(Back-up OIC) (Optional}
'. . Maine:
f.s: tfir'Ie Lost . Jr.Sr.etc.
Cert Type 1 Number. Work Phone:(_ 1
Signature: Date:
"I certify that I agree to cw designation es Sack-u. Operator ir.Chet;_for Cie fart iity noted.I understand and will abide by t he rules ar:d
regulations pertaining to the re;pcnsibi:i?ies set forth in 15A NCAC G8F.0203 gore fairing to do so cats rest:,in Disciplinary Actions by the
�'�'aterPollution Control System Operators CertificationCommissior"
--'4-
t /A
`' Owner/Permittee Name_ �C�i- r"/•//
Phone#: ( t/t1 i
© /�
�' -��,�0 Fax#: (��O ) a y— . eiY v
Signature: "~---- date: V 8/2,.z-)
(Owner . .oriza a
.'A1' el-fail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh.N C 27699-1618 Fax:[phone]
original to: Email;certadminfanedenr.goy
"s•`_,"•
' Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 E Center Ave 3800 Barrett Dr
Swannaroa 2877e8 Sui:c 714 Suite 301 Raleigh 27609
Fax:[phone] =aye:tevi1le2850:-5043 Mooresville28115 Fax:[phone]
Phone:[phone] Fa':910.486.0707 Fax:[phone] Ph0ne:919.791.42011
lyric en:910.433,3300 Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq Mall 11.2"Cardinal Dr 450 W.Hanes Mall Rd
:: tt
Washington 27889 1':i.niceton 28405-2345 Winston-Salem 27105
lz,iFax:232.946.9215 Fax:[phone] Fax:[phone]
'*.' Phone:[phone] Phone:[phone] Phone:[phone]
(Amin a copy on this form for your records)
Revised 05-201 s