820236_Operator Designation Form_20190131

0619, 11:46a - p.5
•• � Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F.0201
Facility1Farm Name: ""'i '' J
• Permit 4: Alff 0 U;.3 6 Facility 1Q#: 2 3,1 County:
•
Operator In Charge(OIC)
Name: V V. ,n C•20 G - /e.,`lei.2
t.! First M1P+ddle Last Jr.Sr.err
•
Cert Type/Number: A /010 cc'70) 'Work Phone:( (G' ),- G 2 - i i-1 Z
, - f Dare: ! '3/ �.7
Signature:
":c rtity that i agree to my designation as the Op rator in Charge for the facility noted.I understand and will abide by the rules and regulations
pertaining to the responsibilities set forth 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[a Charge(Back-up O1C) (Optional)
°s : Name:
rieS1 !.fiddle Last Jr.S,•.'etc
Cert Type/Number: . Work Phone: 1, 1
' Signature: Date: -
"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 set forth in 15P.NCAC OF.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution.Control System Operators Certification Commission."
,'Y,r - nn
Owner/Permittee Name: {ra-tP'j�}le F r -4 �C ' I }-lt/- . ,uj 1A
ter ? n
Phone t?:( 9 i11 } ��I . 3�.� .3 Fax#: ( ez ,ei 1 0 - 76-
Signatrtre: Q , P Dale: 1 =3)-1 9
(Owner or authorized ag -
Mail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Email:certadmitt ncdenr-aov
. :Hail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 2255 Green St 610 E Center Ave 3800 Barrett Dr
• .Swannanca 2877S Suite 714 Suite 301 Raleigh 27609
• Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone] •
Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone]
Phoen:910,433.3300 Phone:[phone]
Washington Wilmington Winston-Salem
';;.i,:. • 943 Washiniton Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
•
Washington 2'7859 Wilmington 28405-2 84 5 Winston-Salem 27105
';�'_.� Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
(Retain a copy oj'this form for your records,
Revise)05.2DIS