090016_Operator Designation Form_20200424

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Animal Waste Management System Operator Designation Form
WPCSOCC 'tt
NCAC 15A 8F.0201
Facility/Farm Name: 1)1a .- a D
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Permit#: 'C °Li VC1 IP Facility ID#: ! . I/ County: 6{1
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Operator In Charge(OIC) p
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Name:
First Middle Lau Jr.Sr,et.
Cert Type/Number: O �I Work Phone:(Z32- 1,.5,19,f
Signature: � t-/��....-• Date: �Z1 Zl/
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"1 certify that 1 agree to my designation as the Operator in Charge for the facility no:ed.1 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 F i
Pollution Control System Operators Certification Commission." rr
Back-up Operator In Charge(Back-up OIC) (Optional)
Name:
First ittidd!e La.tr . Jr.Sr,etc.
Cert Type/Nutrber: Work Phone:( )
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Signature: Date: t a •,I
"I 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
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."
Owner/Permittee Name: 1)Q (,• ttbThrl
Phone#: --M - �VU Fax :1qi a) StZ' q t[6 b •
Signature: 1 ` ,`-
Date: r .W.,,
(Owner or authorized agentj`�
Mail,fax or email the WPCSOCC, 'All-Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Email:eertad acdenr,eov
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Mail or far a copy to the Asheville Fayetteville Mooresville Raleigh y
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 E Center Ave 3800 Barrett Dr
Swannaaaa 28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] Fayettevilla2E301-5043 Mooresville 28115 Fax:[phone] §E
Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone]
Phoen:910.41,3.3300 Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal D: 450 W.Hanes Mail Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:336.776,9800
(Retain a copy of NHS fo1,7i for your records)
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