090124_Operator Designation Form_2020052020

19 20,05:44p Barwick Agservices 9105900074 p.3
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ystem Operator Designation Form
Anima? Waste Management S
WPCSOCC
p NCAC 15A BF.0201
Facility/Farm Nrame 1 r.�.s 4- 6r r.,% , )4 3
/ >Permit#: u/2 y Facility 1D#: q - /29 County: f�l
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Operator In Charge(OIC)
Name: .>;n 4 �an re 1 ems+
First Aliddic Last ✓:Sit etc.
Cert Type/Number: 9gS1,,�I Work Phone:(`T/0 ) 77 -• /jG cY
Signature. 7c,...._ /2.4- Date: S'/,s'r20aT
"i certify that]agree re my designation as the Operator in Charge for the facility noted.[understand aid will abide by the rules and regulations
pertaining to the responsibilities set forth in l5A NCAC 08F.0203 and failing to do so can result in Disc:O Lary Actions by the Water
Pollution.Control System Operators Certification Commission.-
Back-up Operator In Charge(Back-up OIC) (Optioned)
Name:
f•7rrt ,.fiddle La:(- Jr.Sr,etc.
•
Cert Type/Number: Work Phone:(
Signature. Date:
"I certify that I agree to my designation as Back-up Operator in Charge for the facility noted.I undershirts.and will abide by the rules and
reguations pertaining to the:esponsibilities set forth in'15A NCAC 08F.0203 and failing to do so earl result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
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OwaerJPermitteeName: Njerme..5 r4Yi t C+c " Jt'•-
Phone#:( 5Ve ) C 'S--9532. Fes:
5 isattsre: ;-i.-- t r DatE :5'.-A- o2a?1?
f or authorized eat)
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