090039_Operator Designation Form_20200511

1620, 12:12p BarwickAgsetvices 9105900074 p.1
•
Animal Waste Management System Operator Designation Form
t=;: . . WPCSCCC
NCAC ISA 8F.0201
Facility/Farm Name: /f,G k (44 d4•- hi K.. 3
Permit#: Ai i s a O a 2 7 Facility IBr: . q • 3 1 County: azed l+,.-
•
Operator In Charge(01C) . .
i1. {�
Name: IV t C�0\
m 6 S " C.TY GV\G i{1 . 5 00.6 L 0 .
First Middle Last Jr.Sr.etc. Cll� II +
Cert Type J Number: 9 �, 5, Work Phone:( I j O } � I — 3 1 l
Signature: N11.,t \ _ £ I I V �0
Date:
:'.i , "I ceni, agreeY designation by g
'":<<'z ;�� ,_ _ `yth2t I :o to desi atiott as the Operatorin Charge for the facility noted.T understand and`a'111 abide the rules and regulations
;-=_.,=: penaining to the responsibilities set forth in 15A i4CAC 08F.0203 and failing to do so ezn result in Disciplinary Actions by the Water
, . Pollution Control System Operators Certification Commission.-
.
Back-up Operator In Charge(Back-up O CC) (Opiionrxl)
Name: ,
rim 'Middle Lost . Jr.Sr,etc. ,
.::�;;: Cert Type/Number: Work Phone:( )
,s= ' Signantre:
Date:_ -
•
"I certify that I agree ro my designation as sack-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 ISANCAC 08F.0303 and failing to do so can result.in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission." '
Owner/Permittee Name: ILL .
Phone If:( ) ,- ) •) 1 -" I k
• ,` Fax#;1
>; Signature. { , ,
': (Owner or authorized agent)
Date:-s" C1
I
Mail,fax or enroll the W1'CSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Irh,eil_certadertha }nedenr.gov -
4lail or fax u copy to the Asheville • Fayetteville
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610E Mooresville 380Ral0iB
{' Swannanou 28778 610 E Center Ave 3800 Barrett Dr
;,;5;. :. Suite 714 28301-5043
Suite 301 Raleigh 27609 Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
,'.g,"'`i; Phone:828.Z96.4500 Fax [phone]
:?,1;;= Faxr 7Q4.663.6040 ?hen a;919.791,4200
Phoen;910.433.3300 Phone:704,663.1699
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
•
•
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
Ii$roan a Copy of tills_Orin jot' •ou1'recordS)
.. Revinnl D5-2015
:rid
l