82019_Operator Designation Form_20190131

•2619,05:14p ' p.1
Animal Waste Management System Operator Designation Form
' WPCSOCC
""4` NCAC ISA8F.0201 •
• Facility/FarmName: -741 r.ke
Permit#: Pli,3T2 12 9 Facility IDti: ro' - /-, County: „ _��
. r
Operator In Charge (OIC)
Name: 1( 7 4,?"... u./k u
First / Middle Laa: Jr.Sr,etc.
Cert Type l Number: -27 S- Work Phone:( T/O ) .�t��'',7 .b.�/t .
Signature, / 1]a '+.c.•--- b----__ Date: A3/1 f
"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 08F.0203 and failing tc do so can result in Disciplinary Actions by the Water
aA.'f;t ' Pollution Contort System Operators Certification Commission:'
Back-up Operator In Charge(Back-up OIC) (Optional)
Name: .
First Middle Last Jr.Sr,etc.
•
Cart Type/Number: Work Phone: ( ) ' '
Signature: Date:
"t 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 perta:ning 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/I'ermittee Name: UT-fry 5-4wv .�{,v.
-,- • Phone#: fq(0J. 30, -,?`(V Fax#:( ) - .
`,, ' :„. Signature: � / • Date:
(Omer or a norized agent) ,
Mail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Email:certadmiri ncdenr.aov
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
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609 .
', -•:-:l` -' Fax:[phone] Fayetteville 28301-5043 Mooresville28115 Fax:[phone]
''''' Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone] i
"�„.,:24`i•;r Phoen:910.433.3300 Phone:[phone]
Washington Wilmington Winston-Salem
913 Washington So Mall. • 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmington 284 0 5-2 845 Winston-Salem 27105
'. Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
(Retain a cop.'of this form,(or your records)
Revises 05 2015
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