090023_Operator Designation Form_20200424

2 20.04.33p Barwick Agservices 9105900074 p.10
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC ISASF.0201
Facillty(Fa�rAmn Name: U J(Sj1
Pertnit;i; rt'ti-socloa23 Facility ID#: / - �3 County: a&E ,_
Operator In Charge(OIC)
Name: / {L� 14'0S \
Firs( Alirink � Last Jr.Sr.rte.
Cert Type/Number: �' Work Phone:( .5 - )s"b/2-/,625-#
Signature: Date: 9 2(/.[/
certify that I agree to my designation as the Operator in Charge for the facility noted.I understand end will abide by the riles and regulations
pertaining to the responsibilities set forth in 15A NCAC 08F.0203 end 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 O1C) (Optional)
Name:
Rest Middle Last_ r.Sit eie.
Cert Type l Number: Work Phone:( )
Signature: Date:
"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 I5A NCAC 08F.0203 and tailing to do so can result in Disciplinary lotions by the
Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name: DQ(L11 C,' tY1
Phone#: `e.1,lr!. r2- • 14'01a Fax#:f qi O} ¶(I'Z- q 46.._4111 b
Signature: NI' Dates —Z4_2029
(Owner or ontoorizcd
Mall,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone] original to: Fgtail:certadadn a7-ncdenr.zov 44,,
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 E Center Ave 380D Barrett Dr
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 2830i-3043 Mooresville 23115 Fax:[phone]
Phone:[phone] Fax:[phone] Fax:[phone] Phone:919.791A200
Phoen:910.433.3300 Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mali Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
Fax:[phone] • Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phonet 336.7769800
(Retails a copy of this form for)our records]
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