820194_Operator Designation Form_20190402

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Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 0.0201
Facility/Farm Name: ` 4- a 1 M;e It,.-
Permit 4: 4-kJ 2 6 f !-1 Facility IDax: - /99 County: sC :
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Operator In Charge(OIC)
Name: h,l.,s „
First Afiridie Lek lit Sr,etc. - .
Cert Type/Number: `�` �s� Work Phone:( %/Cl 1 S%� SS"
Signature: Q V Date: q —,A i y
•'i certifif that 1 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 I SA NCAC 08F.0203 and failing re 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.
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Cert Type/Number: Work Phone:( )
Sigrlatttre: Daze.'
-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 se: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."
Owner/Perntittee Name: Ctn...., o Z.---1 -C.
Phone#:( 9101 9 9° ` //G Z Fax#:( )
Signature: .AL Date: — —/y'
(Owner or authorized agent': .
Mail,fax or email the WPCSOCC, 1618.Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
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original to: Email:certadmin(a�ncdenr.gov -
Afai1 or fax a copy to the Asheville Fayetteville Mooresville Raleigh
'.;: •;;:-, appropriate Regional Office: 2090 US P,.;y 70 225 Green St 610 E Center Ave 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite 301" Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 Mooresville 281 1S Fax:[phone]
Phone:[phone] Fax:[phone] Fax:[phone] Phone•919.791.4200 '
Phoen:910,433.3300 Phone:704.663,1699
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•'• Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
•• Washington 27889 Wilmington 28405-284S Winston-Salem 27)05
Fax:[phone] Fax:910,350.2004 Fax:[phone]
Phone:[phone] Phone;910.796.7215 Phone:336.776,9800 .
(Retain a com:of this•form for•your reco)'dsl
Revised 05.201.1
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