090039_Operator Designation Form_20190409

Apr 1219, 11:56a p,2
Animal",',',as.: .,•42 nagernent System Operator Designation Form
WPCSOCC
CAC 15A 8F.0201
•
Facility/Farm Name: iv_ ct- 6sole. A-, 3
Permit#: MA'S 0 10 a 3 9 7acility IN: ( - 3 I County: 46\
Operator n Charge;(O` )
Name: - / •q f,
r,st Al1.1du L.*; Jr Sr,etc.
ti Cert Type/T J umber: } ' '" / j 7j Work Phone:(?l 0 ) 1 7 V-- /7-•�
Signature: Date /4' 1 rl/
"I cerify that I agree to iny designation as -rator in C,arae for the facility noted.[understand and will abide by the rules and regulations
t< per..aming to the responsibilities set forth.i:i 15-, :c. ^8F.0203 and£Filing to do so can result in Disciplinary Actions by the Water
Pollution Control System Opera-ors::err. ;'o:t c-n'-'ica."
Back-up Operator In Chary a(. r_k-•t-: ' IC) (Optional)
Name:
Jr.Sr.rtc.
Cert Type 1 Number: —— Work Phone:(
Sigitarttre; _ Date:
"1 eerily that 1 agree to my cesignatiot as ba ;::);e,•ator un::-.a-ge for the facility noted.I understand and will abide by the rules and
regulations pertaining to the responstbiGt es;:' ::',in!5A NCAC 08F 0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Orn_ra; rs Cc-::r_:°-,,-Cct",r,SS:o:t."
OwnerlPermittee Name: _Iti, litl 46Y1'
Phone#: ( j(t% �?V-3 0/( .. Fax#:f )
(LIt 'Signature: Date: /�
`r' i :Owner or aathoraed:.gear;
--'-=
Mail,fax or email,the W.^CS,. -. ; :8 Mail Service Center, Raleigh.NC 27699-1618 Fax:[phone]
original to: Email::eerta. tninnncdent•.nov
Mail or fax a copy to the Ashevilk Fayetteville Mooresville
appropriate Regional Office: 2090 Li ;y 0 :25 Green Si 610 E Cen:er Ave 380 380 0 Raleigh
Barrett Dr
Swennar J S Suite 71.1 Suite 301
gh 27609
Fax:93; > •) Fayetteville 28301-5043 Mooresville 28115 Fax:t919.571.4718
Phone:3 a.,1 4500 Fat:910.486.0707 Fax:704,663,6040 Phone:[phone]
Phoen:910.433.3300 Phone:[phone]
h'ashingtan • Wilmington Winston-Salem
943 W.shingo:r So Mall 127 Cardinal Dr •150 W.Hanes Mall Rd
'.Vashingto::271tt19 ;'ilmirgton 28405-2845 Winston-Salem 27105
Fax: [phone],E Fea:910,350.2004 Fax:[phone]
Phone:252.`�.4:1.5.481 Phone;910.796.7215 Phone:[phone]
,1.2rair, ::crn.n'at this for•rn jot your records)
Revieni Of-2015
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