820006_Operator Designation Form_20200424

di;i_iy 12 20,04:29p Barwick Agsetvices 9105900074 p.1 -
Animal Waste Management System Operator Designation Form •
WPCSOCC
NCAC 1SASF.0201
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'!.i ' •. Facility/Farm name: Con a n „, Fi,,,.. •
r,,ju4 Au ,b 6 �'
r;; Petmitn: J b ��t) Facility ID#: County: / 1 v im`'
Operator In Charge(OIC) , • ,
Name:•2 15d bY1 i/�'»Sp� ,
r
Arr,a I Middle Lest Jr.Sr etc.
• y s y:. Cart Type/Number: / Work Phone:(ZSL ), ,p-J 'f#
t}. r�yt: • Signature: t^— Date: '7'24/-�
"I certify that I agree to my designation as the Operator in Charge for thefacility noted.I understand and will abide by the rules and regulations. :
pertaining to the responsibilities set forth in 15A NCAC 08F.0203 end failing to do so can result in Disciplinary-Actions by the Water •
Pollution Control System Operators Certification Commission."
Back-up Operator In 'Charge(Back-up OIC)-(Optional) . : ,
'ar; Name:
Ittisi Middle last_ Jr Sr,etc:
:;- "_` Cert Type/Number: • Work Phone:( )
Signature: Date: '
i
"I certify that 1 agree to my designation as Back-up Operator in Charge for the facility noted.'understand and,will,abide by the rules and i `
regulations pertaining to the responsibilities set forth in 15A.NC/aC 08F.0203 and falling to do so can result in Disciplinary Actions by the - ..I
• • Water Pollution Control System Operators Certification Commission."
`t 43wnerllPerrnitteeName: �Q(� L' t-1, 4 fo t.l
j u' Phoned: OO ` -Fax#:(qiO} 9�`�- q46 b
Signature: Date;
4-2t-)Z9
(Owner or authorized agent)
Mall,far or email the WPCSOCC, 1618 Mall Service Center. Raleigh.NC 27699-161S Fax:[phone]
{ original to: ,-Email:certadminna ncdenr.gav
t:i+=F'i;? `, ' 4fall or fax a copy to the Asheville Fayetteville 3' Mooresville
-`_ xv.'+ .'; , 2090 US Hwy700lBs
:' 4;.;-r x.1.:', r appropriate Regloltat Office: 225 Green St 61 D E Center AveA 3800 Barrett Dr
-'`" "l.-6:" ' ,Swennanoe 28778 Suite 714 Suitt 301 Raleigh 27609
Fax:[phone] Fayetteville 28301-5043. Mooresville 28115 Fax:[phone]
•
Phone:[phone] Fax:[phone] Fax:[phone]' Phouet919,791;4200 '
Phoen;910,433.3300 Phone;-704.663,1699 _
Washington ' Wilmington Winston-Salent
943 Washington Sq Mali 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmington 28405-2845 Winston-Snlcm 27105 -
Fax:252,946.9215 • Fax:[phone] Fax:[phone] 4
' Phone:[phone] Phone:
•ri,A ',F ,_-,.• , Phone:336.776.980Q
r1-A-,"•-'' u erain a copy ofthis form 0r ar SJ
1:.,:in i. �. f for your t?C ti
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