820098_Operator Designation Form_20191218

Jul 13 20,02:17p Barwick Agser'vices 9105900074 p.1
Animal Waste Management System Operator Designation Form
WPCSOCC
• NCAC 15A 8F.0201
• Facility/Farm./Partin Name: VY0-r is"r "►'+`"-s .•/D /S
Permit# PRAJ: c'2 6 b.1?.1( Facility TD#: 0)-- - QVCounty: $ -s"'
•
.Operator In Charge(OIC)
Name: 'J (.t,4-� cis¢-i'+ �" •
First p, Middle .Last Jr.Sr,etc. ./y
Cert Type/N Ad �.�7 7 Work Phone: ( 47/)1 ,) V 1//3
Signature: 1411 , Cipl. ,�9,,.- �.ii' Date. ' ,JJ'4 J/
• "1 ceruy that 1 agree to my designation as the Operator in Charge for the facility noted._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."
Back-up Operator In Charge(Back-up OIC) (Optional) •
Name: .
Hat Middle Gast. Jr.Sr,etc.
Cert Type;Number: • Work Phone: ( )
•
Signature: Dare:
• r; •
- y.,,-, "I certify that 1 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,"
OwnerlPermittee Name: • ivll1tc, . /rLR fro. W re`
Phone#: ( '/o 3 '4'll3 Fax#:I )
Signature: t'l1,)( _.. ,6'____ �6,0-s- Date. , / V if
(Owner or authorized agent) / Z /
Mail,fax or email the . %VPCSOCC. 1618 Mail Service Center, Raleigh,NC 27699-1618. Fax:[phone]
original to: Email:certadmin(aincdenr.gov
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
•
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 E Center Ave 3800 Barrett Dr
Stvannanoe 28778 Suite 714 • Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:[phone] Fat:910.486.0707 Fax:[phone] Phone:[phone] '
` Phoen:910.433.3300 Phone:[phone]
Washington. Wilmington Winston-Salem
943 Washington Sq Mail 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone] •
(Retain a cop"ofthts/Dent for your records)
Resised 05.2015 -