820103_Operator Designation Form_20190131

1°ar 06 19, 11:52a • p.9
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A SF,0201
Facility/Farm Name: "` 'mil t-—/Ili
Permit 4: PIv'S 11/i3 Facility IDS: ?�- /13County: . t- I ram--,
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Operator In Charge(OIC)
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Name: V1✓ILe'e+ � � Z�"�
First tfiddlc Last Jr.Sr.ere. (�
Cert Type/Number: A /00 COO Work Phone: ( yrl j'� '1
C74, /1 �
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Sigratur-e: _s ' • Dare: cf
"1 certify that 1 agree to my designation as the rater in Charge for the facility noted.I understand and will abide by the roles 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."
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Back-up Operator In Charge(Back-up OIC) (Optional)
Name: •
Firs: tlyddle Last Jr.Sr.err.
Cert Type/Number: Work Phone: (
Signature: Dare:
"I certify that 1 agree to my designation as Back-up Operator in Charge for the facility noted.[understand and will abide by the rules and
regulations pertaining to the responsibilities set forth in I 5A NCAC 0RF.0203 and failing to do so can result in Disciplinary Actions by the
\Water Pollution Control System Opera:ors Certification Commission."
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Owner/Permittee Name: ��� - e� � �G Ant b. s .sr.le j
Phoned:: i 9/01 4)`1r- 3s.Y 3 Fax :t if 't 0 O7C _G
. .- Signature: Gv Dare: ""
(Owner or authonzcd age
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Mail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax: [phone]
original to: Email:certadminCa7nedenr.aov
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwv 70 225 Green St 610 E Center Ave 3300 Barrett Dr
Swannanca 28778 Suite 714 Suite 301 Raleigh 27609
Fax:828.299,7043 Fayetteville2E301-5043 Mooresville28115 Fax:[phone]S
Phone:[phone] Faa:910.486.0707 Fax:704.663,6040 Phone:[phone]
Phoen:910.4_3.3300 Phone:[phone] .
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmingron 28405.2345 Winston-Salem 27105
Fax;252.946,9215 Fax:[phone] Fax:[phone]
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Phone:[phone] Phone:[phone] Phone:[phone]
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(Retain n copt of•this form for your records) •
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rievised C3-2ot)