820234_Operator Designation Form_20190610

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Jun 1019,03:42p p.2
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Animal Waste iiilanagement System Operator Designation Form .
WPCSOCC
NCAC ISA SF.0201 -
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Facility/Farm Name: retAArliU ,;. ,
Permit 4: 5.8aD Facilit}'ID#:00-- - County:
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Operator In Charge(O1C)) .
• Name: id .�/-1-- 4 6i2 rHrct9 •
First Middle Last Jr,Sr,etc.
. Ceti Type/Nui er: � -`; �/ tV2- Work Phone:( /�) l y 7/�
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Signature: II Date:_a- 1D-11 fir .
'9 certify that I agree to my designat n as t Operator in Charge for the facility noted.]understand and will abide by the rules and regulations
pertaining to the responsibilities set in 15A NCAC OSF.0203 and failing to do so can result in Disciplinary Actions by the Water
Pollution Control System Operators Certification Commission.' - ,
Back-up Operator In Charge(13acic-up OIC) (Optional)
' • Name:
First .d1icldle. Lost Jr.Sr,etc.
Cert Type/Number: Work Phone:( ) .
Signature: Date: .
"1 certify that I agree to thy designation as Back-up Operator in Charge for the facility noted.I understand and tell abide by the rules and
regulations pertaining to the responsibilities set forth in 15A NCAC 03F.0203 and Failing to do so can result in Disciplinary Actions by the
• Water Pollution Control System Operators Certification Commission.".
. Owner/Permittee Name: ,e0 4f -" 4/lei a 4,,a,
Phone n:( �/C) ) 1/"/—77 5� - Fax#: ( )
Signature: r! /, — -.- Date: . .4 �,C-2 —
(Owner o authorized agent)
Mail,frrx or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Email:certndmin r(}r ncdenr.gov
Mail or fax a copy to the Asheville Fayetteville Mooresville , Raleigh
appropriate Regional Office: 2090 US Hwy 70' 225 Green Si 610 E Center Ave 3800 Barrett Dr
•.. Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
.},. r Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
'•'_"- . Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone]
.- Phoen:910.433.3300 \Phone:[phone] •
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Washington Wilmington Winston-Salem
943 Washington Sry Mall 127 Cardinal Dr 450 W.1-lancs Mall Rd .
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone] ' '
(Retain a copy of this form for your records) •
Revised O5-20I5
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