780097_Operator Designation Form_20191227

)8 20, 12:49p Barwick Agservices 9105900074 p.1
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A SF.0201
Facility/Farm Natne: J y 1 Ck Cr o O _EAL_G f j
Q.
Pennit#: Pori 7 st L 011 Facility 1D4.4: 7'- F 7 County: R o t ,
Operator In Charge(OIC)
N,:re: KQ.t.tavIClE. dRrQ �� EG, p,11
a!iddir Lo.'• Jr.Sr.etc.
Corr Type r Nyiltber: jai Work Phone:( )10 ) e t 1- 9171
Signeaur•e:r' �` Date 7-
certify that:Barre TO my designation as the Operator in Chatga for the faciliy noted.I understand and will abidr by the rules and regulations
pertami.rg to the responsibilities set forth to 15A NCAC 08F.020 and failing to do so can result,n Disciplinary Actions by the Water
Pollution Control%stern Operator::Certification Commission.'
Back-up Operator 1 i Charge(Back-up O1C) (Optional)
Nau,r:
•st 411,4 r L.rir Jr.Sr.cf..:.
Ceri Type/Number: Work Phone:(
S:gnanire: Date:
":c:ratty that I agree to my ce;ignation as Back-up Operator in C'::arge for the facility noted.I understand a.id will abide by Lie rules and
r,gulat:otts pertaining to the responsibiltt::s sot forth ir.15.A NCAC 03F.0203 and failing to do so can resu.t in Disciplinary Actions by the
Watt-i'ollutior Control System Operators Certification Commisston.'•
Owner/Pertnittee Name: IL
Faxrt:; }
Date. ^�' J9
Sigr:at;n•e: __-- e I��< C'
(Owner or aadta•:ze;,agent)
)fail,fax or.email the WPCSOCC, 1618 Maii Service Center. Raleigh,NC 27699-1618 Fax:[phone]
nrixi:nrl tur Email:certudmioOnedenr.eov
Mali or fax is copy to the Ashe.ilk Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 CS Hwy 70 _25 Green St 610 F.Center Ave 3800 Barrett Dr
Swanrwnon 28778 Snit::714 Suite 301 Raleigh 27609
Fax;828 299.7043 Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:[phone] Fax:[phone] Fait:704.663.6040 Phone:919.791A200
?lion:910.433.3300 Phone:704.663.I 699
Washington Wilmington Winston-Snlen;
943 Washm_ron Sc.\•iatl :2 7 Card.nat Dr 450 W.Ht.nus Mail Re
Washington:7889 s'ilmiugtun 2s4O-2345 Winston-Saint:7I05
Fat:252.946.9215 i st:910,350.20134 Fax:[phone]
Phone:[phone] P Cwwne:910.796.7215 Phone:[phone]
fRefatrt a copy ot!his,toter/or rcur re:o%•4h•,
a.v.ed JJ-'_UiS