090005_Operator Designation Form_20200424

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Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F.0201
Facility/Farm Name: Frr•-dLe5 , 'r-
Qf1 �f
Permit 4: P 1 D 4 o, e C Facility ID#: % - S+ County: �l ,
Operatoror In Charge( (OTC)
Name: Rb/ 1 11f9Mzj�, V I'h5i9 r\
First Middle V Lao. Jr.Sr.etc
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Cert Type/tiumber: _�6 n g'� '� Work Phone:(ZSZ is-bp--j�� , s1
Signature: / .,__ Date: L �� i` g
":certify that I agree to my designation as the Operator in Charge for the facility rested.I understand and Aril:abide by the rules and regulations
pertaining to the responsibilities set forth in ISA NCAC 08F.0203 and fail ir.g:o do so can result in Disciplinary Actions by the Water
Pollution Control System Operators Gratification Commission."
Back-up Operator In Charge(Bade-up OIC) (Optional)
Name: '
First Middle Last . Jr.Sr.etc.
if-','
Cert Ty;e/Number: Work Phone:( ) '
Signature: Date:
"I certify that I agree to my designation as Bad:-:rp 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 a:d failing to do so can result in Dtsciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
all
Owner/Permittee Name: DQl::3' C' HI'11.6Y r
Phone 3:1` CQ - -1400 Fax#:(6'1 O) NI-- 0 �6
Signature: 15-- '`'`r.,~'"` -_-. rr r
(Owner or authorized agent)
Date: ,,K' Z`7
Mail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh.NC 27699-1618 Fax:[phone]
original to: Email:certadtain('la ncdenr.aov
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh ',ti
ro riate Re nal 2090 US H 70 '
app p Regional Off-ice: Hwy 3?.5 Greer.St 610 E Center AveAue 3800 Barrett Dr �°1''"
Swannanoa 28778 Suhc 714 Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 2833:-5043 Mooresville 28115 Fax:[phone]
Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone]
Phoen:910.433.3300 Phone:[phone]
•
Washington Wilmington Winston-Salem
943 Washington Sq Mail 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmington 2640S-2845 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone] 41r`
(Retain a copy of;hi:form.for your records;
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