820112_Operator Designation Form_20181130

•01 2019 06:09PM HP Fax page 1 / RECEIVE O
DEW .
Animal Waste Management System Operator Designation Form .SIN U", 2g59
WPCSOCC
NCAC 15A 8F.0201 WORDS
Facility/Farm Name: 1)10. i'tt pt./ A 3
Permit : 770"5 e`�D/1/� Facility ID#: F��` - //2" County: � --
:-a
_ Operator In Charge(OIC) , .)J •
Name: TA", f `Gi'.-4 Ii•lick,
Firer Middle Last Jr.Sr,etc.
Cert Type/Number: Work Phone: ( (7/� ) 5/T U- OY
Signature: t U r e_ t:.t (�• Date: ( / >w'i,
"1 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
•F; -.• pertaining to the responsibilities set forth in 15A NCAC 0SF,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 Middle Last Jr.Sr,etc.
Cert Type/Number: Work Phone: ( • )
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."
Owner/Permittee Name: Val a Jl
G. t Phone#: ( //O ) 5 I U - 77 U Fax#:( ): <=
Signature: fk Li Lip4j ^ k Date: 1 3D •I t
( ner or authorized agent)
. Mail,fax or email the 'WPCSOCC,. 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Email:certadmin().ncderar.eov
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
j,;4,;• / Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
>,•t+•�, Fax:[phone]- Fayetteville2i+301-5043 Mooresville 2811S Fax:[phone]
Phone:[phone] Fax:[phone] 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
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:[phone] •
•
Phone:[phone] Phone:[phone] Phone:[phone]
(Retain a copy q(this form for your records)
'l�w``i:,:,
y�;;�?,.,.,, Revised05.2015