090035_Operator Designation Form_20200924

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Animal Waste Management System Operator
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WPCSOCC
NCAC ISA 8F.0201
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Facility/Farm Name: `>V-e- 't C;
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operator in Charge(OM
Name: C_e ei c 114 f.,(
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i Cert Typ e i Number_ /S'c7 9Z v
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"I certify that 1 agree o m drsi Date, :12
Piny to r Y gnatiota as the Operator in Charge for the facility responsibilities set fortis in ISA NCAC 08 F.0203 and failing t noted.1 understand and a;yi abide by n ks
Pollution Conc of Sysean Operators Certification Commission... t:
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N result in Disciplieary geNons���r�egttim�
Back-up Operator In Charge(Back-up 01C) (Optional)
Name:
First ,there
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Type I Number:
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I certify that i teQ:LY to my desig tatior.as Back.
"! iot s atpertainingese to the up Opsator in Charge for the facility noted.I understand and will abide
Water r Pollution COnty:Svc min o i ra�set
forth in iSA?JCAC 08F.0203 and failing to dose can result in i by the ruins anti
'tons
by the
Operators Certification Commission." Ac
Owntr/Permitt:ee Name: Q
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S'ignanow r - --
Dare:�`'�
x,er or audte.^ized agent) \ _z•L�Z'�
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'}Tail,fax or email the WPCSOCC, 1618'Maii Service Center, Raleigh,NC 27699-1619 Fax:[phone]
original ro: Email:certadtninfdncdenrror
,"v.,, Mail orfax a copy to the Asheville Fayetteville
Moonsville S1 aPprepriate Regional Office: 2090 US Hwy 70 ti5 Gruen St 6I0 Rakish
Swannaetota26775 Suitc7t4 61301CannaAvt 3alatgb tettDr
Fax [phone] Fa}sille 28301-4043 Suite 301 27609
Phone:[phone] Fax:[phone] Fax:744.663,6044 PPbone•:91 .4200
Phoea:910.433.3300 Phone'704.663.1699
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450W.Hanes Mall Rd
Washington 27889 Wilmington 28405-284S Winston-Sake,27105
Fax:232.946,9215 Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
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' aterata a copy of this form for your records'
Rr vsrJ 05--2015
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