78077_Operator Designation Form_20190912

16 19.07:34p Barwick Agservices 9105900074 p.2
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 1SA 8F.020/
Facility/Farm Name: i (a
Permit#: S 7S"0 0 77 Facility IN: ,_ 77Coutty: reD �se-%
Operator In Charge(OIC)
Name: 8(.4e .. La.. NW-V.'S
First Lflddttene Last Jr,Sr,etc.
Cert Type/Number: /DO L?3r j Work Phone:(�'Q ) . ,r- 2( 7
Signature: iLdL /V yS Date: y/2 /7
"i certify that I agree to my designation es the Operator in Charge for the facility noted.I understand and will abide by the rules
and regulations pertaining to the responsibilities set forth in 1SA NCAC 08P.0203 and failing to do so can resuh in Disciplinary
Actions by the Water Pollution Control.System Operators Certification Commission."
Back-up Operator In Charge(Back-up OIC) (Optional)
•
First Middle Last Ir.Sr,etc.
Cert Type I Number: Work Phone:(
Signature: Date:
"I certify that I agree to my designation as Back-up Operator in Charge for the facility noted.I undeastand and will abide by the
rules and regulations pertaining to the responsibilities set forth in ISA NCAC 0817.0203 and falling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Ccanmission."
/
Owner/Permittee Name: t'2
Phone#:S /1/ ) — ---+ems ?Jo)
Signature: Date:
era t }
Mail or fax to: WPCSOCC
1618 Mail Service Center
Raleigh,N.C.27699-1618
Fax:[phone] •
•
• (Retain a copy of this form for your records)
Revised 8tIOO7