780077_Operator Designation Form_20200424

. 2 20.04:34p Barwick Agservices 9105900074 p.11
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC ISA 8F.0201
Facility/Farm Name: 61) fbq� w�i
Permitii: ltw. 11f) 0 -17 Facility!DO: 7 - 4i,,,,,
77 County;
Operator In Charge(OIC) ,/
Name: ?J le✓f�- V tbis Jt\
Firs; Middle Lam Jr.Sr,etc.
Cert Type/Number: l'�'j r Work Phone:(Z3l. }SbQ-JflS
Signature. y-- Date: 942q- (,
1 certify that I agree to my designation as the Operator in Charge for the facility noted.I understand and will abide by the ruks and regulations
pertaining to the responsibilities set forth in 15A NCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the Water
Foliation Control System Operators Certification Commission.'
Back-up Operator In Charge(Back-up OIC) (Optional)
Name:
Fltat Middle Lem- Jr.Sr,era !
Cert Type/Number: Work Phone:( 1 i
1
Signature,. Date:
•
'I certify that I agree to my designation as Back-up Operator in Charge for the hail icy noted.I understand and will abide by the rules and
regulations pertaining to the responsibilities set forth in I SA NCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the
•
Water Pollution Control System Operators Certification Commission."
i
Owner/Permittee Name: bQ( (,• `io-'^1 i
Phone#: ti' " 40 U i
Fax#:(g1O) s3 - g4bID
Signature: Date: l —2,4"ZOO
(Owner or authorized agent)
e
1
• Malt,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Entail;certadmin(a)ncdenr,gov
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US H 70 225 Green St p p7' 610 E Center Ave 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax;828.299.7043 Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:828.296,4500 Fax:[phone] Fax:[phone] Phone:[phone]
Phoen:910.433.3300 Phone:704463,1699
1
Washington Wilmington Winston-Salem i
943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
Fax:252,946.9215 Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone] i
(Retain a copy of this foal for your records) .
nevh,t 05-2O5
E
i
i