820030_Operator Designation Form_20200924

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WPCSOCC
Waste Managetrent System Operator j' to "
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NCAC ISA 8F-0201
- `<Y-L¢'. Facility/Farm Name: ^_1 c i 1
Permit :Ak/Jr.. r50 z acility
t:' 'T i,s• , - County:
' -' `;::.,'>':«:r.: Operator an Charge((O1C)
`: ,2 Name: L.e e t e.h et t'•cf g ro t,J,-)
4, fits: itlddlc La<f Jr.
[. • Cert Type??Number: /, a D e!K 3 c,
:.' s;1 - Work Phone: 7-}
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r 5; � [ce::i fy6 that I agree co my designation as the Operator in Charge For the facility noted I and-stand and will abide
pertaining to the respoasfi iiities sit forth in iSA•t.ICt,,C 08F.0203 and failingto do so
Pollution Control System Operators Certification Commission can rtsult in I)isai In by the r:l� ater nations
s, P asy.4�rions by tiic Water
'?; ,-s>.,., Back-up Operator In Charge -�
g (Back-up O1C) (Optional)
Name:
,`�s',i 1.it% s ' l7rsr h;i tilt
=z°te• a, •sS,.' ,y Sr.et:.
,F7.� f Cei Type i i`Iu�tber:
'j1A.-Ili: _ Work Phone:{___—
' c' Siznarzere: ----
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..erd that 1 agree to mar dmigiatiot:as Boric-up Operator in Charge for the facility
, • regulations penaining to the tesponsibili:ies set forth in l5A NCAC 08P.0203 a tod. o so a and and will scipl- A the rules and
1.4 a--•'Pollution Control System Operators Certification Commission." �d failing to o so t result in 1]iyc9plir ry Actions by the
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,I;t•i..Ci.4 .Y OwnerlPermitree?Name. Del. t 1SY
?Y Phone L 11): 1._-NO
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:lV.rr` ',l Signanire:" ~�._. --____
(Owner orau ha-i?ed aged:- -_�,` Date:_ � �"j�
- . _hail,fox ar ear:az?the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27649-1618 Fax:'919.715.2726
. orig.nalto: Email:certadrinfyJacdenrgay
-,: Mail or fax a copy to the Ashe'lie Fayetteville
-:.`; {s, x appropria1e_Re;ionalOfte: 2090 US HW3'70 225 Green St 610E iilc tabu
*-3. : .x Swarmanoe 28778 'Suite 711 Centel Ave 3E00Rafe gh2Barrett De
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<' Suite 301 Raleigh 27609
:,,,;-..t-,_Y..;;'' ,;• Fax: 249.7tit3s Fzyrttevilla2830I-5043 tvSoorLriy,ao281IS 16is::919571.4738
4a y ' _', Far:910,4E6.0707 Fax [phone]
Plioen:9i0.433.3J00 Phnna:704 63.1699 Phone:919,9914200
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Washington Wilmington WinstiinSaiem
943 Washington Sq Mall 127 Cardinal Dr 350 W.Hales Mail Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
-';:;::,:^: ' Fax:[phone] Fes:9103502004 Fax:[phone]
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=,n 4:.': !Retain a co v v of this form for your records)
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