090073_Operator Designation Form_20200127

18 20.02:34p
Bar.vick Agservices 9105900074 Lij
DEQ/DWR
FEB 18 2020
Animal Waste Management System Operator Designation Form
Faeility'Farm Dame: L
Perrrit 4: _ Ay � Zlb % 3
Operator In Charge (OIC)
Name: / r 1. G yG p
WPCSOCC WQROS
NCAC 15A8F.0201 7AYETTEl/li l PD[=('1ni ,a► r)FFICF
t:, fe-N Asf
Facility 1D#: - 7 3 County: 1/4- c%
Firm AWN, Las;
Cert Type / dumber:_ & r7 a e? -3
Jr. W , etc
Work Phone: { 1
Signature: &,j'M'gga..__.r--_� Date: �'•2 .ZCt
" certify that I agree ro my designation as the Operator in Charge for the facility noted. I understand and will abide by rite rules and regulations
pertaining Co the responsibilities set forth in 15A NCAC O8F .0203 and failing to do so can result in Disciplinary Actions by the Water
PoLution Contral System Operators Cem:fication Commission:'
Back-up Operator 1n Charge (Back-up O1C) (Optional)
N arne:
Cert Type I .Number:_
Signanwe:
Middle Lasr . Jr. Se. ere.
Work Phone:
Date:
"I eer,:fy that I agree to my cesignation as Back-up Opcmtor in C:arge for cite facility noted, I understand and wit! abide by the mtes and
reguEitiors penaining to the responsibilities sec forth in ! 5A NCAC 08F .0203 and `aiiing to do so can result in Disciplinary Actions by'the
W�-tcr Poilurior. Cont701 System Operators Certification Commission."
Owner/Permittee Fame:
Phone #: L. ql0 _ �, - Y%S� Fax#: ( I
Signature: � (11.,C� Date: 1-2 %-.2o-i-o
;Ownerorau•r rizedagenti
Marl, jar or email the WPCSOCC, 1618 .Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Email: certadmin(@ncdeur.¢ov
Mail or fax a copy to the Asheville
Fayetteville
appropriate Regional Ogee: 2090 US liwy 70
:15 Green St
Swannanoa28778
SL.rc?14
Fax., 828-299,7043
Fayetteville 28301.5043
Phone:[phone]
Fax:[phone]
Phoen: 910.433.3300
Washington
Wilmington
943 Washington Sq Mali
M Cardinal Dr
Washington 27889
mi:tgton 28405-2845
Fax:252.946.921zz
Fax:[phone]
Phone-. 252.946.6481
Phone. [phone]
R:Vlsed as-2c 15
Mooresville
Raleigh
610 E Center Ave
3800 Ba-rea Dr
Suite 301
Raleigh 27609
Mooresville 28115
Fax: [phone]
Fax:704,663,6040
Phone:[phone]
Phone: 704,663,1699
Winston-Salem
450 W. Nanes tvlall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
(Aetain a cope o77kis jot7)1 fof Your mcordsl