090040_Operator Designation Form_20190409

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Apr 12 19, 11:56a
Anfirr.;:-."''' ::.--.1. rragent System Operator Designation Form
WPCSOCC
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y41 44 Facility/Farm Name: _ 4,,,, F4...... 0- l
Permit 4: 41'1 C Of te'fo .:acili::„ :Ti# 7 _Ya County:
. .. Operator In Charge(OK". I
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Name: /4,-//1(—.
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rs: ,t,ti :',.c 1...:.^, Jr .Sr.etc.
Cert T e/Number: Ati4 .T2L Work Phone:( 9/0 ) ii711 -fif 7)--
Signature..
Date: (I- %-/ ct
.1 certify that I agree to try designaton id:.i:..:!..p.rator•n:Marc?!fDr the facility noted.I understand and will abide by the rules and regulations
per.aining to the responsibilities c.v.:tr.t,. i:- I.:." : ::NC cm F.0:::03 and failing to do so can result in Disciplinary Actions by the Water
Pollution C.7ontroi System Ope:rOrs ir.:..,.:Itoc:•:.?.:!0.: .3tilm:ssion
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, —....._ —Back-up Operator In Ct.e.7.1.(7..,..7.-.!...;-• ;-! 21C) (Optional)
Name:
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LT.,' Jr..3,.etc.
Cert Type i Number: Work Phone:( ,
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Signature
Date..
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"I certify diat I agree to my tiesignaiio7-.25 r.1%..;:;:-lo)Ootraror in Cilzsge for the facility noted.I undentanc and will abide by the rules and
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regulations pertaining to the respons:Oili: -.!•::-:-o7.1-in SA NCAC C8F.0203 and fairing to do so can result in Disciplinary Actions by the
Water Pollution Comml System Operatxs(.:----::ti.:,)ri C:tininis,:t'II-
OwneriPermittee Name: g St "re.
Phone#: ( gia '.; f 11 - 3/i i Fax#: ( i
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.j'-:!;',• Signature: Lk l-trl-
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!Owner..or authorz7d ageni)
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Mail,fax or email the 717PC5,7 ,.._:. '.518 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Email:ct:r13.,5.minaucdenr.2ov
Mail or fax a copy to the Asbeviil.,• Fayetteville Mooresville Raleigh
appropriate Regional Office; 2090 US ji.v.7 70 223 Green St 610 E Center Ave 3800 Barrett Dr
Swannzno.c,;;.;377!:. Sunc 714 Suite 3C 1 Raleigh 27609
Fax:13l'.29,s"74..3 Fayettevale 28301-5043 Mooresville 28115 Fax:[phone]
Phone::n3.29-.1.4500 Fax:[phone] Fax:[phone] Phone:[phone]
Phoen:910.433.3300 Phone:[phone]
1.vashingie:a Wilmington Winston-Salem
(I.33.Washingtor So Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
Washing:on 289 Wilmington 28405-2845 Winston-Salem 27105
Fax:2S2.)45.311S Fax:[phone] Fax:[phone]
Phone:25:.C,'.6.6481 Phone:[phone] Phone:[phone]
a copy qr this.trai-nip?your records)
Revised 05-2015
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