820202_Operator Designation Form_20200512

• 21 20.05:12p BaiwickAgservices 9105900074 p.1
Animal Waste I1lanagement System Operator Designation Form
• WPCSOCC
NCAC 15A 8F.0201
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Facility/Farm Name: ;5-1 4.1 ri G.1 s ' J '
Permit g: &I Sr L'4,(9 .� Facility IDax: r ? - 2CAc
County: Jc
Operator In Charge(OIC)
. .. Na tne: pill i -l: �. 1 Lea
.Firer r iffrldlc Lan in Sr,ere.
. Cart Type i Number: L- vi: �� r J
� �� Werk Phone: ( //�' 1 �� ' 7v,11
Sigtian:re: f" =,.,71i' % y-r!
L� Dare: Y.,,i,- -:__/
"1 certify that i agree to my designation as the Dper- in Charge for the facility noted.I understand and will abide by the rules and regulations
pertairang to the responsibilities set forth in 15A N ,-.0 03F.0203 and failing to do so can result in Disciplinary Actions by the Water
Pollctior.Control System Operators Certification ommission."
Back-up Operator In Charge(Back-up OIC) (Optional)
Name:
•
• rim. ,6t!ddie Lost . . Jr.Sr,etc.
Cert Type f Number: Work Phone:( )
Signaurre. Date:
"I certify that 1 agree to i-ny designation as Sack-up Operator in Charge for the facility noted.I understand and will abide by the noes and regulations pertaining to the responsibilities set forth in 15A NCAC 08F.0203 and riling to do se can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission." -
SOvtneriPermittee 'dame ..j vta17 ,..t..,.,t;a
Phone#r: (�l/G/ ) - �f E C% eel/ In/0-10 .'/(S' Faxir: ( )
•
Sigr:a:I e: •(t( (' -!/hi1 1p'.-r✓' Date: • 5--12 2O .O
(0hvne or autl/-ized agent)
•
}fail,fax or email the WPCSOCC, 1618 1tai1 Service Center. Raleigh,NC 27699-161 S Fax:[phone]
origitral to: mail:certadmi.n(atnedenr.Tov
Mail or fax a copy to,the Asheville Fayetteville Mooresville Raleigh
• epproprime Regional Office: 2090 US Hwy 70 225 Green St 610 E Center Ave i 3800 Barrett Dr
Swennanoa 28778 Suite 714 Suite 301 Raleigh 27E09
Fax:S28.299.7043 Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:[phone] Fax:[phone] Fax:[phone] Phone:9I9.791.4200
Phoen:910.433.3300 Phone:7D4.663.1699
1,''ashinuton Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W.•Hanes Mali Rd
Washington 27889 Wilmington 28405-2345 Winston-Salem 27i05
Fax:[phone] Fax:[phone] Fax;336.776.9797
Phone:252.946,6481 Phone:[phone] Phone:[phone]
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r ert,an a cop:'or tili5 Coro:jot'Yotn•records)
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