090168_Operator Designation Form_20190409

. 4aGr 12 19, 11:56a p.1
' Aninnai�:a i,4anagerent System Operator Designation Form .
wPCSOCC •
NCAC 15A 8F A201 .
acility/FarmNa111e: ilTyG �od c�c� z-, , •
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Permit#: z //
(?`�C�� Facility fGF: f =��� county: .
Operator In Charge(Oitr J
Name: /� th
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First ,Ifi tie -r kVA-,dc•� La,r, Jr.Sr,e:c.•
Cart Type.t Number: 9S736 . Work Phone: ( I I/ 'i I,V -t//72 .
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Signature: Date.. 11-"11 `
:`; "[certify that I agree to my designation as the Opara[or in Charge for the facility noted.iunderstand and wilt abide by the rules and regulations
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,_: penatnin3 to the responsibilities set forth in 1`r-'.'`t(;'.0 CV.0203 and failing to do so can rest;t it:Disciplinary Actions by the Water
^; ` ,- Pollution Control System Operators Certification Corlmtssion."
' Back-up Operator In Charge(3ack-~-n-01C) (Optional)
Name: -.
1'irrt
• wrird:, Jr,Jr,etc. - .
Cert Type/Number: -- Work Phone:( ) " ,
:ss Signazatre: �� Date:
"1 eertity i that 1 agree to y designation asBack-ur:Operator in Charge for the tacilitynoted.I understand and will abide by the rules and
regulations pertaining:o the responsibilities set%:r h in 1 SA NCAC 08P.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Cer.ii cat:en C'ommasioa."
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OwneriPermittee Name: 1',,,,4'_tl;=G//t •
' Phone 4:f 7(a 'O r 7 Il I ---- Faxfr: ( ) . _
,'t( l; Signature.. 1 ,_ 'l/
,`;n�.y:" Dare: "
_ (Owner or aurhorixed agent
' Mail,fax or email the WPCS3•CC; 1618 Mail Service Center, Raleigh,NC-27699-1.618 Fax:.[phone]
original to: Email:certadmin{7ncdecr.gov
Mail or faz a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 209011S Hwy 70 • 225 Green St . 610 E•Ccnler Ave . 3800 Barrett Dr
S wan nanoa 28777i Suite 714 Suite 3C1 Raleigh 27609
, T -.- - Fax:[phone] Feye:tet,il1e28=0.-5043 ivlcores•.ilie2ss 15 Fax:939,571.4718 -
:• ;~:R';� Phone:[phone] Fax:[phone] Fax:[phone] Phone:919.791:4200
'i Phoen; 910.433.3300 Phone:704.663,1699 .
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 45G W.Hanes Mall Rd
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Washngton 27389 • Wilmineton 28=05-2845 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:336.77'6.9797
Phone: [phone]S1 Phone;910.796.7215 Phone:[phone]
(Retain copy of this for Inr'to your records) ,
Revised 05•2015 • .