090126_Operator Designation Form_20200424

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Animal Waste Management System Operator Designation Form
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NCAC 15A SF.0201
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• `{• ' , Facility/Farm Name: k �t'S("T a_
' i Permit#: J•- ( I 0/2(a Facility ID#: ! - /2.6 County: s714a L. .
Operator In Charge(01C) ,/
ryr lit: ..., Name: D( /21, 4e-! Y 1�1/l.5e/\
..L `-- First Mirk* ) Last Jr.Sr.etc, .
Cert Type/Number: D g'f ,, Work Phone:(Z52- tf.
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Signature: t.�- Date: 742e1 2� '
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"I certify that I agree to my designation as the Operator in Charge for the facility noted.I understand and will abide by the rules and regulations -
pertaining to the responsibilities set forth in ISA NCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the Water •
Pollution Control System Operators Certification Commission."
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' - Back-up Operator In Charge(Back-up O1C) (Optional) .
Name:
liar Mider Last. Jr.Sr;etc.
. • Cert Type/Number: Work Phone:( )
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Signature: Date:
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"I certify that I agree to my designation as Beck-up Operator in Charge for the facility noted.I understand and will abide by the rules and • i
•.;a"' , `:• regulations pertaining to the responsibilities act forth in ISA NCAC 08F.0203 and falling to do so can result in Disciplinary Actions by the
.+..'` Water Pollution Control System Operators Certification Commission.".
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Owner/Permittee Name: �Q .Y1 (,` t I r r •
Phone#: - 140 U Fax#:(tt 10) LeZ~ e 6 b
Signature:
Dare: �' 2 —Zc�Z�
n e �-,, - (Owner or authorized agent3 — t
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�` ;'`` • Mall fax the WPCSOCC,
• , I618:V1aIE Service Center, Raleigh,NC 27699-D61A Fax [phone]Z6
r•, original to: Email:certadrain(a'lncdenr.gov
Mall or fax a copy to the Asheville Fayetteville Mooresville Raleigh •
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 E Center Ave 3800 Barrett Dr l
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax:828 299,7043 Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:828.296,4500 Fax:910.486,0707 Fax:704.663,6040 Phone:[phone] 1
Phoen:910,433,3300 Phones 704.663,1699
Washington Wilmington Winston-Salem
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:= 943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd I.
t-''.;'' : . Washington 27889 Wilmington 28405-2845 Winston-Salem 27105 1
i; ,-`tic',:.; , ' Fax:[phone] Fax:910,350.2004 Fax:[phone] l
' , Phone:257_946.6481 Phone:910.796,7215 Phone:336.776,9800
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(Retell!'a copy ojthis form for your records)
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