820096_Operator Designation Form_20190130

. 04 2019 10:54PM HP Fax page 1
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F.0201
Facility/Farm Name: r'141 Y'«Ai,S "r`
Permit#: A1(ii; f 2 0Del)) Facility IDS: p b County: j-
Operator Inn Charge(OIC)
•
Name: ✓ln;ut Lee' s
First • .Afiddic Last Jr.Sr,etc. '
; :',. Cert Type/ umber: / 'J P /V 0')•Y)-3 Work Phone:(' Ql 0 ) -3 C + �o' a
Sigtlantre: ,y_3+:Yx: Date:
11 .) jq
"I certify that 1 agree to my designatio as the Operator in Charge for the facility noted.I understand and will abide by the rules and regulations
i 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." •
Back-up Operator In Charge(Back-up OIC) (Optional)
Name:
First hliddie Last Jr,Sr,etc. ' .
Cert Type/Number: Work Phone: ( )
Signature: Date.
• "I certify that I agree to my designation as Back-up Operator tr.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 Controi System Operators Certification Commission."
Owner/Permittee Name: )'1G�lvty K rr1<ri'T1{v,y ,
Phone#: (9) 0 ) c'11)-' V`I ,,`i Fax#:( )
Signature: `' ) 1) 40- ale: 1-3 D /9
(Owner or author12 gent) ��j�����
`• '` Mail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:919,715.2726
original to: Email:certadmint incdenr.gov
Mail orfaxa copy to the 'Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 E Center Ave 3800 Barrett Dr
Swannanoa 26778 Suite 714 , Suite 301 Raleigh 2,7609
Fax:[phone] Fayetteville 2 8301-504 3 Mooresville 28115 Fax:[phone]
Phone:[phone] Fax:910.486_0707 Fax:[phone] Phone:[phone]
Phoen:910.433.3300 Phone:[phone]
- Washington Wilmington Winston-Salem
�''' 943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
A?f," Washington 27889 Wilmington 28405-2845 • Winston-Salem 27)05
Fax:.[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
(Retain a copy of this form fort your records)
. Rev,sed 05-2015 .