090040_Operator Designation Form_20191022

01 19, 10:15a BanvickAgservices 9105900074 p.1
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC I5A 817.0201
Facility/Far i Name: 114 4 ,f \ 1 C-
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Permit#: r!""(S t 10(��0 facility lD#: q - / v County: 13 LAIn.1V
Operator la Charge(O1C)Name: gyrv1 /�1. / 'Ae f/
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Pi ,,.-Ad/ilk [`LJNI 7 Jr,Sr,err. /� �•/���
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Cert Type/Number: ALAI A 1J 1T 36v — Work Phone:(i } 31[
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Signature: _ Date: 1°/2_ 4
"I certify that I agree to my designation the Operator in Charge li.r the facility noted.I understand and will abide by he rules and regulations
pertaining to the responsibilities se:forth'in ISA NCAC 0814.0203 ensiling to do so ca::result in Disciplinary Actions by thz.Water
Pollution Control System Operators Certification Commission.•
Back-up Operator In Charge(Back-up O1C) (Optional)
Name:
Yi,v4 Middle L.4Yr !r..Sr.ale.
Cert Type i Number: _ Work Phone: ( 1
Signature: Dale:
"I certify that 1 agree to my designation as Back-up Operator in Charge fix the facility noted.I understand and will abide by the rules and
regulations pertaining to the responsibilities set funk in I5A NCAC 081=.0203 and failing to do so can result in Disciplinary Actions by tlx:
Water Pollution Control Sys Wm Operaiots Ccrtilikariun COMM iSSi l...
Owner/1'ermittet Name: 10.5 h r r /4/6( ' .s"
Phone#: (r/i p 1 q 7 Y Z` 1,4 Fax#:( )
signaitire: / _ Date: %(/'~2 2 - i,
Ow w• °rind aganr)
Mail,fax or email the WPCSOCC; 1618 Mail Service Center, 12akigh,NC 27699-1618 Fax: [phone]
original to: Email:ccrtadntinTincdeur.au%
Mail or fax a cope to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 223 Cirecn St 610 ECenter Ave 3800 Barrett Dr
Swannanou 28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] Fa,eLteviIle 28+01-5043 Vluoresv:lle 28115 Fax;919.571.4718
Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone]
• I'hnen:910.433.3300 Phone:[phone]
Washington Wilmington Winston-Salem
„, 943 Washington Sy MalI 127 Catdi:al 1)r 450 W.Hanes Mall Rd
Washington 27889 ll•'uiniugtun 28405-2845 Winston-Salem 27105 •
Fax:[phone] Pea:9111.35(1.21104 Fax:[phone]
Phone:[phone] Moine:910.796.7215 Phone:[phone]
,Retain a cupty ul ill is. Jar your recurdsj
Rev laaxl 0-2013