780077_Operator Designation Form_20200924

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Animal Waste Managernc:nt System Operator U
`':4�a WPCSOCC �i6'aation 'ornl
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a NC eiC 15A 8F.0201
Facility/FarmName• G. /�
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Permit;:: IJ.Sir� Facility iD
County: t�...e.I r=,
Operator In Charge(01C,
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;°`3 Name: L{t Klc71aCc/
`; Cert Type/\T.t:nbcr:, /4iP" 3
,/ •)5.` Work Phone: �c.) 3 7 —Zy .7
Signature: , '
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certify that I agree to my dcsignatior.as the Operator in Charge for the facility
pertaining to the respoasbrlities se:forth in 15A NCAC as.0203 and tailingdo noted.1 minuend M. a^'I'c'Ul abide b
Pollution Control System Operators Cc tiE.cation Commissio do so can it in Disci 1i Y doe rules and eegutatiors
P try Anions by the'Water
t V Back-up Operator In Charge(Back-upOl
C) (Optional)
Nasne:
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Cent Type(Number
-- _ Work Phone:(-______L__
Signature:
Date:
"l certify[haul agree to my designation as Back.
up regulations earl
agree
o rt a oP Operator in Ch:ne for the faciary noted.I tmdetstand and will abide by Me rules and
regul Pollu responsibilities se:forth in 151 NC t..' 03F.0203 and nulls to do so can result in Disc'
f 1F _ tion Contra;System Operators Cetv'?caoon Comm Lis:n3.' rp ivary Actions'ay the
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OwnerTermittee Name: lid LIL f} (Y t t-F-y'
Phone : 1.- ' 140 I.) Faat>*:dAj O
Signature: r`�� y_' -- _
(Owner cr ac haiz d aga \[> Date: "Z.2
'``jda. Mail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-I618 Fax:[phone]
z' i original to: Email:certadmia(a�ncdenrgov
t Mall or fax a ropy tot ,e Asheville Fayetre.ilte Moorasvllte
"': ` ` approAr a Regional O ce: 2090 US Hwy 70 12i Green St Eti
Swar1Jsmoa 28778 Suite 714 610 E Center Are 3800$a nett Dr
609
Fax:[phone] Fayetteville 2830I-5043 Mocute oy01 5 Fsx:919.71.
Phone:[phone] Fax:[phone] ossttr>Jle�1!" Fax:[phone]
Fa::70d663.6048 Phono±9I9.791AI00
! noon:910.433.3300 Phone [phone]
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall R•'
Washington 27889 Wilmington 2 8405-2 8 4 5 Winston-Were 2710f
t; A Fax:[phone] Far:910.350.2004 Fani336.776.9797
Phone:[phone] Phone:)10.796.7215 Phony 336.776.9800
(Retain a cop}'01 this fo;ni for your recordsi
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