820237_Operator Designation Form_20190131

r 06 19, 11:45a p.1
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F.0201
Facility/Farm Name: Hrj t'..J '
Permit A: �1fs �� 3 7 Facility ID#: c - 237 county: _5 O1 -
•
Operator In Charge(OIC) :. •
Name: "
tli t in I n ��.y
1 ONtet.Z- f •
Firs; Middle' La.rr Jr Sr.ere.
Cert Type/Number: /00 ?0 Worlc Phone: ( -/l 1 )'-)7 Z y !/ z
Signature: Date: r3 1
•'I ceriFj that 1 agree to:sty designation as the erafor in Charge for the facility noted.I understand and will abide by the rules and regulations
• pertaining to the responsibil:ties set forth it.. 15A NCAC 08F.0203 and failing:o 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: .
:Z`r'":,`.'f ` . First ,tlyddie Last .r..Sr.err.
Cen Type/Number: Work Phone:( )
•
Signature: Date:
":certify that:agree to my designation as Back-up Operator:n Charge for the facility noted.[understand and will abide by the rules and
regulations 2ertaining to the responsibilities set forth in I5A NCAC OSF.0203 and failing to do so can result in Discip:inary Actions by the •
Water Pollution Control System Operators Certification Comtission•"
'` `` Owner/Permittee Name: � jl � Axe r. t(s.,t I IA
Phone 4: ( ` , ) � •, ' - ,.I , __ 'Fax#: i' 1/0 ) 0 2 - ---C)7C
Signature: Date: I.-3 1'/ r • '
(3vene-or authorized as
Mail,fax or email the WPCSOCC, 16.18 Mail Service Center. Raleigh,NC 27699-1618 Fax: [phone]
` original to: Entail:certadnnint 1ncdenr.eov
,,` Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 ?5 Green St 610 E Center Ave 3800 Barrett Dr
• Swart anon 28778 Suite 714 . .Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:[phone] Fax:910.486,0707 . Fax:[phone] Phone:[phone]
•
Phoen:910.433.3300 Phone:[phone]
•
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmington 28105-2845 Winston-Sale:n 27105
Pax:252.946.9215 Fax:[phone] Fax:[phone]
i'-; ;' Phone:[phone] Phone:[phone] Phone:[phone]
. (Retain o cope of this forum for your records)
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