820243_Operator Designation Form_20190523

Aug 08 19, 10:32a p.2
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Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F.0201
Facility/Farm Name: �tti^w+.5
Permit 14: I V J d Q 0 a,Lf, Facility ID#: 312 -,_93 County: JCc, edv,-,
Operator In Charge(OIC) .
Name: / ' Lid )4„1,a
Fast Middle Last Jr,Sr,etc. •
Cert Type/Number: r N. 4� 22 !0 Work Phone: ( 1
Signature: Vav
,Date: .�23-1 y"I certify that I agree to mydesignation as the Operator 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 08F.0203 and failing to do so can result in Disciplinary,Actionsby the Water
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Pollution Control System Operators Certification Commission."
Back-up Operator In Charge(Back-up OIC) (Optional)
Name:
First Middle Lest Jr,Sr.etc.
Cert Type/Number: Work Phone: ( )
• 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 die Hiles and
regulations pertaining to the responsibilities set forth in I5A NCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name: jr?0„ 7 Call,e
Phone/1:(fit 0) la ,--is ' �Jt'�,1 Fax#:( )
Signrthire: or 6r - Date: 5 '?3 -/ f
(Owner utltoriud agent)
Mail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
' original to: Email:certadmin(et�,nedenr. ov
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 E Center Ave 3800 Barrett Dr
- Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
. Fax:[phone] Fayetteville 23301-5043 Mooresville 28115 Fax:[phone]
Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone]
Phaen:910.433.3300 Phone:[phone]
Washington Wilmington Winston-Salem
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943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
• Washington 27889 Wilmington 28405-2845 Winston-Saletn 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
(Retain a copy of this forrn for your records)
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Revised 0 -2015