820105_Operator Designation Form_20200110

14 20,09:48a Barwick Aggseivices 9105900074 - p.1
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Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F.0201
Facility/Farm Name: e ii" s
• Permit#: /r 1A1 c r1 /O 5 Facility 1D#: County:
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Operator In Charge(OIC)
Name: !titF
First ,,�,fiddle Lad Jr.Sr.etc.
�yU Cert Type/Number: � - a 6 5- , Work Phone: (9/i ) 3�,� �' � •
Signature.' %i• Date.
"I certify that i agree to my designation as the Operator in Charge for the facilitynoted.I understand and will abide by the rules and regulations
pertaining to the responsibilities sat forth in I5A NCAC 08F.0203 and failing:o do so can result in Disciplinary Actions by the.Water
Pollution Control System Operators Certification Commission."
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Back-up Operator In Charge(Back-up OIC) (Optional)
Name: -
i list lfiddie Leer . Jr.Sr etc.
Cert Type/Number: Work Phone:(•
Signature: Date:
"1 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 l5A NCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the
' Water Pollution Control System Operators Certification Commission."
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Owner/Permittee Name:
Prone#: 0 ) 3+ ����T Fax4- )
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Signature: /SR CL ( cfr�3 LZ 6— Date: /`/e—_,2Q3-b
(Owner or authorized agent)
Mail;fax or email the WPCSOCC, 1618 Mall Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Email:certadmiot acdenr.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
Swannanos 28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 283 0 1-5 0 43 Mooresville 28115 Fax:[phone]
Phone:[phone] Fax:[phone] 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 28405-2345 Winston-Salem 27105 •
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
(Retain a copy of this forth for your records)
P..tvia:tl.15-201 i