780097_Operator Designation Form_20200511

20. 12:12p Barwick Agservices 9105900074 p.2
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F.0201
Facility/Farm Name: A cbr,c 1 � di.. ekie
•
Permit ii: S7Y0 a 97 Facility IN: ?$ -r 7 County: I vo yes,
Operator In}Charge(OIC()`
Name: JV11O`
�-Y64S Cs r¢ \CS hl G oot E 0
First l4tlddle Last Jr.Sr.are, + J
Cert Type/Number: 1`C 0 ) �,3 (�5 Work Phone:( 1 1 0 ) f^� - 3 i f,
Signanlre: '�m,1M� - - II " �tJ
Date:
"1 Cerc fy that I agree to my designation as 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 ISA NCAC 08F.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-up OIC) (Optional)
Name:
fl r dfiddk Last Jr.Sr;etc.
Cert Type I Number: Work Phone:( )
Signature:
Date:
'1 certify that I agree to my designation as Back-up Operator in Charge for the facility noted.I understand and will abide by the rules and
reaulatiana pertaining to the responsibilities set forth in I5A NCAC 08F.0203 and falling to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
r'. >r
Owner/Permittee Name: 111,�,�,6 ---
Phone##:Lt � ) ? -- ,II
11 Fax#:( )
Signature: {\J4 9\-- Date: -S-11'20
(Owner or author zed agent)
Matt,fax or email the WPCSOCC, 1618:Mil Service Center. Raleigh,NC 27699-1618 Fax:[phone]
oripbtot to: Ansoii:eortadratneanc Lenr,gov
Mail or fax a copy to the Asheville Fayetteville Mooresville
Raleigh
• appropriate Regional Office: 2090 US Hwy 70 223 Green St 610 3 Center Ave 3800 Barren Dr
Swannenoe 28778 Suits 714 Suito 301 Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:9I9.571.4718
Phone:[phone] Fax:[phone] Fax:[phone] Phone:9/9.791,4200
Phoen:910.933.3300 Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 430 W.Hanes Mall Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27103
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone]I S Phone:[phone]
(Retain a copy of this form Ior your records)
Revised OS-201 t