830015_Operator Designation Form_20200424

2 20.04.31 p Barwick Agservices 9105900074 p.7
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A SF.0201
Facility/Farm (Name: AI 8 1 I
Fcrmit#: i i�1'd1S0 19/ O Facility ID#: - /'' County: �eo KJ
Operator In Charge(OIC)
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Name: 2Q( Aoreir Yr'v7 8 \
FAN Middle Last .In Sr.ere
Cert Type/Number: g I Woric Phone:(Z51- 1S6Q-J,)5—
Signature: yam- Date: 942?2C)
'•r certify that I agree to my designation as the Operator in Charge for the facility noted.I understand sad will abide by tie rules and regulations
pertaining to the responsbtlities set forth in 15A NCAC OIF.0203 and failing to do so can result in Disciplinary Actions by the Water
Pc!Iur'on Control System Operators Certification Commission."
Back-up Operator In Charge(Back-up OIC) (Optional)
Name:
nr.T1 b/fddfr Las,_ Jr.Sr,etc.
Cert Type/Number: Work Phone:( 1 j
1
Signature: Date:
-I certify that i agree to my designation as Rack-up Operator in Charge for the facilitynoted.I understand and will abide by the rules 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 Certification Commission."
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Owner/Permittee Name: IJQ( �,' rn
tom 6 Itm 0
Phone#: 2- ' 400 Fax#:(ql O) 'WI- q LP 6 b
Signature: ----......________________ Date: Li—2_4—21-DZ0
(Owner or amhmized agent`
Merit,fax or email the WPCSOCC, 1618 Mall Service Center, Raleigh,NC 27699-1618 Fax:919.91S.2726
original to: Email;eertacindn6aucdenr.gov
Mail or fax a copy to the Asheville Fayetteville Moorusille Raleigh
appropriate Regional Office: 2090 US Hwy 70 125 Green St 6i 0 E Center Ave 3800 Barrett Dr
Swannenoa 28778 Suite 714 Suite 301 Rstdgh 27609 i
Fax:[phone] Fayetteville 28301-5043 Mooenevf1028115 Fax:[phone] t
Phone:[phone] Fax:[phone] Fax:704.663,6040 Phone:919.791,4200
Photo:910.433.3300 Phone:[phone] 1
i
Washington Wilmington Winston-Salem 4
943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
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Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phony 336.716,9800
(Kerwin a copy o(Iil is,forma,for your records)
Revise)05.3015
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