090151_Operator Designation Form_20200515

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,',`fr; Animal Waste Management System Operator Designation Form
• WPCSOCC •
NCAC 15A 8F.0201
Facility/Farm Name 1- • , r�,.
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-': ' Permit h >: l Facility IT3r1: C /�� '
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Operator In Charge(OIC)
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Narrre: R''.1 ,�
First �l L Q `" r t c 5`� '
Afiddte Last Jr.Sr.etc.
Cert Type/Number: 9 'c�,j l Work Phone: Q1 0
Signature:X-�... �,,�_ �
Date: %5-,20a
>'c"?+`-":. "i cern fy that I agree to my designation as the Operator in.Charge for the facility noted.I understand and will abide by the niles and re
% •''' pertaining to the responsibilities set forth in 15AANCAC 08F.0203'and failing to do so can result in Disciplinary Actions by the Water
Poliut;on Control System Operators Certification Commission."•
gttlattent
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Back-up Operator In Charge(Back-up OIC) (Optional)
- Name:
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Part Middle • Last_
Jr.Sr:etc.
• <<'' :_.;:: Cent Type%Number:
. '. `ieA.:• - Work Phone:(- 1_ •
`y S,rY: Signature.
•Date:
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"I certify that.I agree to my designation as Hack-up Operator in Charge for The facility noted,I understand and will abide by the rules and
regulations pertaining to the responsibilities set forth in/SA NCAC 08F'.0203 and railing to do so can result in Disciplinary Actions by the t
•
Water Pollution Control System Operators Certification Commission."
•
Owner/Permiittee Name: Jay.'te5 ` y('t . 1 (les - t�r> •' •
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phone th(-:5V4 ) C rf -it 53.E ... J •• . .
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, Signature:. fr�� :/,
( wren o:authorized ens). date.:.' . if� (�
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