820206_Operator Designation Form_20200511

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Animal Wgste Management System Operator Designation Form
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WPCSOCC
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NCAC ISA Er.0201
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rneillty,rFarm Name: \-,....... c;v-n---
Permit g: ti--vig. 2D),0 4. ...a.:iiity IDti: P'4 - 2CE; County: --)A-ifir,t •
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Operator In Charge(OIC) '
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Pine Ali'itlic 'Lest I le.S.rt,
• Cert Type!Number: ik.\.n,f I (1 ....1.V\ Work?hone:f(: ) '-'i$0
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Date: 5.-
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"I cunt;that 3 roue TO my dent:anon as he Operator in Charge for the ircility noted.1 understand and wig abide by the mien er.d=guts:ions
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• ,. , pormining to the responsibilities set forth in IJA. CAC OSF.C203 and Itaiing a:do so ean resat:in I/kelp limary-Acirres by the Water
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Polhition Control System Orotnton Cm: m,Commission:
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.i1':,-;'",;''ii': : • - :, Bacit-up Operate:In Charge(Becit-up 010 (Optional)
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' Curt T:epe 1 Nu:abort _ Work Phone:( L__________
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Date:
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-t core/that r agroo to roy doeigarition es Back-up Operamr in Giarge for th:racility acre&I understand aril wilt abide by the noim and
tortnotions pertaining to the responsibilities set forth in 13A MCAC OaF.0205 and failna'.0 On Sown retrunin tisti;liatry Actions by the
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W7197 P alitilicri Control System Op•=ate:s Certification Carr rissicn."
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' .. Afcil,far or ernfril Mc NITCSOCC. 16IS:Wail Service Center, Rent!),NC 27699-2618 Pax:90.735'426 .
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' Afail off.=c copy re the Asheville Fayetteville Invoresvillt. Raleigh
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' • oppoprhac Regional'Of,Ice: 2090 US Hwy 70 223 Green St 010 E Center Ave sees Drieg Dr
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5,Lant.naa 28778 Suite 724 Suite301 Paircigh 27,0IN
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Fax:[phone].,043 Pcpetre,ille 2335I-5043 mentor/ilia 2FI:5 F7x:519.873.1718
Phone:[phone]O0 Fax;910.486.0707 Fan:704.ii63.60 0 P50ne:919.791.4260
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Washington Wilmington Winston-Sakm .
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942 Wishing-ton eiq Phil 127 Cavelinal D: 59 111.Elan=MLIIPA
• Wedlingten 2789 Wiltisingtem 2S405-2545 Winstomgalan2.7105 -
Fax:[phone] Far 910.350.2001 Far 336.76.9797
Phone:2S2.946.548: Phoner 917:796.7215 Phone:[phone]
. ifinliill 5 copy o•Olisforto forycar records!
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