820081_Operator Designation Form_20190131

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Animal Waste Management System Operator Designation Form
• WPCSOCC
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NCAC 15A 8F.0201
Facility/Farm Name: y
•
Permit*: fit4C n 405-'I' • Faci:ityID#: 9 - ri Coun : � -, t"--j7-Ic--,
•
Operator In Charge(OIC) • .
______ Name: t✓t[ei,F G ' / O.Z 57 •
First Middle. - Last Jr Sr.etc.
Cert Type/Number: 'A /00 C '1O Work Phone:( GI/t) )J 612—r1'1 2-
c ,) . .
Signature: ''( Date: l f 31-I CI
"1 certify that I agree to my designation as the for in Charge for the facility noted.I understand and will abide by the rules and regulations
pertaining to the responsibilities set forth in I5A NCAC OSF.0203 and failing to do so can result in Disciplinary Actions by the Water •
Pollution Control System Operators Certification Commission."
•
Back-up Operator In Charge(Back-up O1C) (Optional)
Name: ,
First Middle Lasr Jr.Sr,etc.
'i; ; Cert Type 1 Number: Work Phone:( - 1
• • Signature: Dare:
•
"1 certify that I agree to my designation as Back-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 15A NCAC OSF.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
Owner/Ferluittee Name: ��. , Avv
n
y Phone#:( 110t ) 12- �)3f •
Fay::(-i 0 } 2 4)7
Signature: 'S Date: - t �3)--/q
6tONmer or authorized ag
,Hail,far or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
' original to: Email:certadsuin(a.nedenr.aov
Mail or fax a copy to the Asheville ', Fayetteville' Mooresville Raleigh
ss appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 E Center Ave 3800 Barrett Dr
• Swanranoa 28778 Suite 714 _Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
' Phone:-828.296.4500 Fax:910.496,0707 Fax:[phone] Phone:[phone]
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 27859 Wilmington 23405-2345 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:[phone]
' Phone:[phone] Phone:[phone] Phone:[phone]
!Retain a copy of this foiwz for your records)
- Revised O5.2015
i .