090081_Operator Designation Form_20200512

t,'ay 13 20.08:34p Barwick Agservices 9105900074 p.1
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Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A SF.8201
Facilit).'Farm Name: �trt(' G % '�• y
Permit x ti>0Y.t)v$J Facility l►Dtt: 9• - County: /4/e.l 44
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Operator In Charge(O1C1
Kant: lr,,,r, L44su P'1tS}
firs: "fiddle Lan Jr,Sr.rrc.
Cerc Type t Number: 9.n5 7,5/ Work Phone:; 9/O j 4'74 -/.34S
: Signarnrc: G-.. L..y /2--t Dare: 5-/.L-10 20
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zerafy that i agree to ray designator.as the 4?eratot rn Charge for the facility noted.l nrrlerstaad ardour abide by the rules and rcrJlatians
F...cintnt;to the respansibilr in set forth in 1SA NCAC OSF.J:03 srad failing to Co so can moll in Diselptinsty Actions by the Wt c
Pollution Control System Operators C xt.rteation Communion
Back-up Operator In Charge(Back-up OIC) (Optional)
Kahle:
,1r141.! Lter Jr S:cr..
Cott Type number: Wari;Phone:( L
Sig:tslure: Dais:
'1 certify that:agree to illy deaignot:on t4s Back-tip Operator in Charge for the facility noted.I taidatstand and wi.1 abide by the rules nod
rev:Lotions nenatain$to the:espansibilities set foeth to:SA NCAC OSP.O203 and falling m do so can mall la Disciplinary Actions by the
W to Pollution Comrci System Operators Certification Cotranistaon."
Owner/Permitted Name: /2.4... i F�+�-+— 44C—
Phone tt:i 9/01 6'/.5 C4 9 l Pao:( 1
a3 p7 Stxnwitrre: !rt -..� _ Dais: S-!2-JLl:t 0
Khmer or autorunl agent)
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,~fail,fax ar email the WPCSOCC, 1618 Mail Service Canter. Raleigh.NC 27699-1618 Fax:[phone]
ori(Faol so: plan:errtad.ninantedenr.eov
Vail or fax a copy mthe Asheville Fayetteville MooreerBUC Raleigh
appropriate Regional Office: 2090 l:S lfwy 70 225 Green St 610 3i Cuter Ave 3800 Bezel D:
uonncnua 2S77b Su]tc 714 5tu c 301 Role$:27(09
Fax;828.299.7043 Fayettevi11e28301.5043 Mooresvllle28115 Fax:[phone]
ramie:828 296.4500 Fox:910.486.0707 Fax:704rW.6040 Pho0e:919.791.4200
Plloca:910A33.3310 Phone:[phone]
Washington tv:lmsngeon WinstaaSaleas
i 1.l : 943 washin• on Sq StsO 127 Ctudiaal Dr 450 W.Hates Mall Rd
Wash import:7889 V:3mingtoa28409.2845 Winston-Sgeq:7103
Fax::[phone] Fas:910.350.2004 Fas:336.776.9797
Phone:[phone] Poulin 910.796.7215 Phone:[phone]
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