820096_Operator Designation Form_20190522

23 19,01:32p p.1
•
Animal Waste Management System Operator Designation Form
WPCSOCC -
NCAC 15A,8F.0201
f•
. Facility/Farm Name:' Aic 4-e. I M.k rat;5 �ct''--
" Permit#: AO S a �ooq Facility ID#: C/? - 76 County: '- St^
(, ,
Operator In Charge(OIC)
• Name: N 17Ae1 /%/) e "' ,-
First Middle Last Jr,Sr,etc. p �/
Cert Type!Number: _� 3 6 3 Work Phone:( 9/0 ) /77 D-10 0
•
.: ". SignaSignature: • "aioeef;e:j%Woe Date: 2-2- 1 /o� ,
"I certify that I agree to my designation as the 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"
Back-up Operatorin Charge (Back-up OIC) "(Optional)
•
Name:
First Middle Last Jr.Sr,etc.
•
Cert.Type/Number: Work Phone: ( 1
•
Signature:
Date:
"I 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 08F.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
_ `; fYi icIt f 1 .v�3
`,-t�; . Owner!Permittee Name: � '
Phone#: (110 1 q ft `qla l Fax#:( 1
Sigrzatar•e--.'
...01)4.0Ce '� Date: S--`�2/q '
(Owner or authorized agent)
Mail,fax or email the WPCSOCC, 1618 Mail Service Center,, Raleigh,NC 27699-1618 Fax:[phone]'26 .
.,.r.." • original to: Email:certadmin a ncdenr.gov ,
,
...,!..:,I-.r Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
' 2090 US Hwy 70 225 Green St 610 E Center Ave 3800 Barrett Dr
::_ appropriate Regional Office:'';t-r Swatutanua 2877S Suite 714 Suite 301 Raleigh 27609
. 'Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:[phone],00 ' Fax:[phone] Fax:[phone] Phone:[phone]
Moen:910.433.3300 Phone:[phone]
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]
,w,r Phone:[phone] 1'hone:910.796.7215 Phone:[phone] -
(Retain.a copy of this form far your records) •
devised 05-Ot 5,