820080_Operator Designation Form_20200512

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Animal Waste Management System Operator Designation Form
WPCSOC1C .
NCAC 15ASF,0201
..ft ;s' Facility/Farm Name: -li s A/ / �aS�-1 7A.-- � .
Petn�it#: kV S Ora Facility ID#: D - �% County: " +,��.
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• ,, Operator In Charge(OIC) ')1,
�II.LY 1IN '1
Key- `., First - Middle Last Jr Sr,etc, f -
.Vi : ~? Cert Type/Number: I!1'/r /17)7 9 Work Phone:( /'�i 3l.t �a �'2- •
•gr e: 71-k4V2,4-4.-
�y 1 Sr tat/a l,� Al- ,t.c'`' date:'• S/�f�/ Ci
"I certi;y thaCl agree to my designation as the Operator in Charge for the facility noted.I understand and Vvill abide by the rules and regulations'
pertaining to the responsibilities set forth in 15A NCAC 08F.0203 and failing to do so can result in1Disciplinary Actions_by the Water --.
Pollution Control System Dperatnts Certification Commission.' .
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`4yf ` Back-up Operator In Charge(Back-up OIC) _(Optional) '
Firm ,btiddte • ' ' Last . Jr.Sr,etc. -
Cert Type/Number: Work Phone:( " ; . )
1Szgnature: _ Date.' . '
^[certify that I agree to my designation as Sack-up Operator in Charge for the facility noted.1 understand and will abide by the rules and
,,..,w, .' regulations pertaining to the responsibilities set forth in 15A NCAC OSP.0203 and failing to do so can result in Disciplinary Actions by the •
s_..; Water Pollution Control S,stem Operators Certification Commission."
OwnerlPermittee Name: -=\ tki E 'iD JJA R DS jC,YL—ON ' ` •
1 :Phone#: ( lO ) 3?z • 69O� Fax1 : (- ) ' -
• `Sigrattire: IP -L,-7,.t' z'z� 1 Z: r� �.2
Date:
lOunar or author zed agent) /
?" g WPCSOCC, 1618 Mail Service Center, Raleigh,•NC 27699-1618 Fax [phone]
14; hfrtil,fax or email the '
'.`,,,),Iii'`F '.:','', :.ari Hal to: • ]� " `-:s4 ,,,,-:; mail:ccrtadmla(a7ncdenr.siov
,5-,_ . ;:: . ?Mil or fax a copy 10 the • Asheville Fayetteville Mooresville Raleigh -
appropriate Regional Office: 2090 US Huy 70 225 Green St •610E Center Ave - 3800 Barrett Dr - '
Swannanca 28778 Suite 714 • Suite 301 Raleigh 27609
' , - Fax:[phone] Fayetteville 28301-5043 „Mooresville 28115 Fax:919.571,4718
' Phone:[phone] Fax:[phone] , Fax:[phone] Phone:[phone]
Phoen:910.433.3300 Phone:[phone]
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' Washington Wilmington Winston-Salem
r,.'.4, '. ' 943 Washington Se Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
c'+`^,;,;;_ , Washington 27889 Wilmington 28-05-2845 Winston-Salem 27105,
-,„:!4`"''":'~' Fax:[phone] Fax [phone]
. ,+,.3. Fart:252.946.9,225
,,;..g�-:=, Phone:[phone] Phone:[phone] Photte:336.776.9300
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