830015_Operator Designation Form_20200408

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Animal Waste Management System Operator Designation Form
WPCSOCC
�ICAC ISA 8F.02Q1
Facility/Farm Name:
/1? i -3" I
Penr:it#: PgAS r310/ 5 Facility 1D.: 83 • /.County: -lc "qur,i
- Operator In Charge(OIC)
:
;. : Name: JOAii 1✓'�, /1 r cr h 'S CSS01-6
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.• .f Firs: hlyddlc Lest Jr.Sr.are
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Cer tt Type!Number 4 :�+;I w45ie /GC la�4/4/ Work Phone:( l d i 3 3 3 "/ai 7/
Signst:u e. 4/ , e/ 'nay---- Date: —t —X L)0
':eerily that;agree to my designation as the Operator in Charge for::ie facility noted.I understand and will abide by the rules and regulations
pertaining to the responsibilities set forth in 15A NCAC OSF.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-u OIC) trnnal
Name:
;:else kiddie Las: lc.Sr.etc.
Cert Type/Number: Work Phone:( )
Signature: Date 7
} "} I certify that 3 agree to my designation as Back-up Operator in C_;ar_e for tie facility rcted.I understand and wi:1 abide by the rules and
v
regulations pertaining to the responsibilities set fort::in 15A NCAC O8F.0202 and failing to do so can result in Disciplinary Actions by the
Watcr Pollution Control System Operators Certification Co:ttnissicr:.-
• Owner/Permittee Name: ..JC4... +'alz,.
Phone#:i 9r16} d fS -41 ' !' C,
Fax : �llV I 4�-' 1 yf c
Signature: 1-p--- Date: ('�/J (Q �y
r " Tom-"_---- / `�/Zf7 L/J
3• ! IOWrrCPO �t Or'zeQ:`gCRi-'
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i j ' Alai!,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Ismail:certadmintiiiinedcnr.gov
Mail or fax a copy to rice Ashevile Fayetteville Mooreavllle Raleigh
appropriate Regional Office: 2090 US Hwy 70 22:Green St 610 E Canter Ave 3800 Barrett Dr
Swannanoa 28778 Su':c 714 Suite 301 Raleigh 27609
Fax:[phone] =ayr:te,ille 2830:-50.3' Mooresvt3le 28:I5 Fax:[phone]
Phone:S28.296.4500 =a\:910.486.0707 Fax:[phone] Phonet919.79I.42&Q
t
Pacer;910.433.3300 Phone:[phone]
41' Washington Wilmington Winston-Salem
a.: 943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mail Rd
Washington 27889 Wiimineten 28105-2845 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone' 252.946.648I Phone:[phone] Phone:[phone]
(Retain a copy oi'this form for your records)
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