820064_Operator Designation Form_20190910

- -.1419,05:14p Barwick Agseivices 9105900074 p.1
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Animal Waste Management System Operator Designation.F'orm .
WPCSOCC ., ,
. NC4C 15..4.8F.0201
Facility/Farm Name: ���Qf L �� - �NU�y ch •
' Permit#: 4(l; --S2'2 d 00 6 if Facility lD#: �2 - G 9 'County: Sys-, • • '
• t ,
n;: " Operator I Charge(OIC)
` Name: • tlj5
,•first Middle Last Jr,Sr,etc.
Cert Type( �/Number: ! Q f 78j�9 Work Phone: ( !`d ) : :,• "�� �g0`� �'
Signature:' - • Date: `7 f 1( 011
"I certify that I agree to my designation as the,Operator in Charge for the facility-noted.1-understand.and will abide by the rules and'regulations
.,',. ; :',:; . pertaining to the responsibilities set forth in 1 S A NCAC 08F.0203 and failing to do so can remit in Disciplinary Actions by the Water
- Ppllution Control System Operators Certification Commission." ,
Back-up Operator In Charge(B)Lck-up OTC)
(Optional) ` ,
/;\ Name: OentniS Q
• J" fe1 h `
•
Fuss Middle J Last Jr,Sr.etc. . , .
//jj ��t b 1• Work Phone:(� VO ) I D �� '
Cert Type/Nurriber: 1T W j
•
s: Signature: `LI-2-� al..„." Date.` /�—1 j —/,.
"I certify that I 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 15A NCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission." t ,
Owner/I'errnittee Name: /c1 ��i„ L,h !
Phone#:(ill D ) ,qk- y,./r Fax#:( • )
Sig7tat:tre: Date:
(Owner or authorized agent) . /
Mail,fax or email the WPCSOCC, 1618 Mail Service Center; Raleigh,NC 27699-16i8 Fax:[phone] '
-" original to: Email: certadmin r(r7ncdenr.gov . • " .
• Mail or fax a copy to the Asheville Fayetteville Mooresville • Raleigh
':• appropriate Regional Office: 2090-CIS Hwy 70 225 Green St 610 E Center Ave 3800 Barrett Dr -
:,ti,-:. , Swannanna 28778 Suite 714 • ' Suite 301 Raleigh 27.09 t .
Fax:[phone] Fayetteville 2330I-5043 Mooresville 28115 Fax:[phone]
.. ..58<:rs,.: -. Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone] ,
• Photo:910A33.3300 Phone:[phone]
. Washington Wilmington Winston-Salem'
943 Washington Sri Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmington 2 8 405-2 84 5 Winston-Salem 27105
t Fax:[phone] 'Fait:910.350.2004 Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone] _
(Retain a-copy of this form for your records) - .
,b s> . 'Revised 05-20i5 '
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