820007_Operator Designation Form_20200424

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Animal Waste Management System Operator Designation Formyk ,s.
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NCAC ISA8F.0201 i f
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Facility/Faarin Name: P' i Le
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Permit4: b'AY 0O 67 Facility TM: Fa - 7 County: •-)a.:-i'5=�,
Operator In Charge(OIC) '`'`` ,7x
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Name, Zek V V 1'r).Sp n ,
Flrsr Middle ) Last Jr.Sr,ere. - :ry'' .:v
Cep Type I Number: 0 Work Phone:( 52- ).cc�-,/, -
Siglature: Date: V 2 2� ••
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"I certify that I agree to my designation as the Operator in Charge for the facility noted,l understand and will abide by the vales and regulations .: _5!"t`
•" - pertaining to the responsibilities set forth in 15A NCAC UBF,0203 and tailing to do so can result in Disciplinary Actions by the Water i�,<•��,,;;���.
Pollution Control System Operators Certification Commission-" !. �-,ti
Back-up Operator in Charge(Back-up OW) (Optional) • -•
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Name;
l7as1 Middle Las:- Jr.Sr,arc.
= -- Cert Type/Number • Work Phone - - - ----- . - .'• '-
Signature; °_j.
Date: ' '.•;c,-
-'1 certify that 1 agree to my designation as Back-up Operator In Charge for the facility noted.1 understand and will abide by the rules and
regulations pertaining to the responsibilities set forth in 15ANCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
k Owner/Perrnittee Name: •bi 031) L' C l ' ti l. a t -
Phone#: `Z' • 40v Fax#:(' 1O PLfl.- b
Signature:
el /ire.' i4 2 1 — -L�� :-;':-',.:b,:-,:,,,,,,,,,,'f' ,
Date: z .
,L fS(Owner or authorized agent)
Mail,fax or email the WPCSOCC, 1618:Kfaii Service Center, Raleigh,NC 27699-1618 Fax:919.715.272E
original to: Email;cartndmin( peelenr.o_v
Mail ay fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 tJS HMI 70 225 Green St ,610 n Center Ave 3800 Barrett Dr
Swennanoa 28778 Suite 714 Suite 301 Raleigh 27609 w
Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone] ,,.,;;;,
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Phone:828,296,4500 Fax!910,486.0707 Fax 704.663,6040 Phonet919.791,4200
Phoent 910.433,3300 Phone:704.663,1699 `tvl,•^ .
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Washington Wilmington Winston-Salem
943 Washington Sq.Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wi[mh:gton 28405-2845 Winston-Salem 27105 - '
Fax:25a.946.9215 • Fax:[phone] Fax:[phone]
Phone:252.946.640[ Phone:[phone] Phone:[phone]
(Retail a copy of this foratfor your records)
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