820257_Operator Designation Form_20190523

rj 0819, 10:32a p.3
•
Animal Waste Management System Operator Designation Form
WIPCSOCC
NCAC 15A 8F.0201
Facility/Farm Name:
L.dy.2. . A-r7,,s ;3
Permit#: ktlds gQ 0 AZ 7 ' Facility lD#: 5'2 -zS 7 Coi nty: S� se,-
Operator In Charge(OIC) - -
Name: L' �j'J tt f a oef
First Middle Last Jr,Sr,etc.
Celt Type/Number: /24 67 T5-2 Va Work Phone:.( ) -
Signature: ( 1 ,yl � Dale: ' S-2 3- )
"1 certify that I agree to my designation 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 Actions by the Water
?ollution Control System Operators Certification Commission."
Bade-up Operator In Charge(Back-up 01C) (Optional)
Name: •
First - Middle Last Jr,Sr,etc.
}r�_ • Cert Type/Number:
3T 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 the rules and
regulations pertaininito 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."
Owner/Perntittee Name: j a� .L'ei -e
Phone#:('it C ) n 3 S 3 f Fax#:( )
Signatttre:� ''' Date: �� '��j
• (Owner cjuthonz ed agent)'
Mail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Email:certadminancdenr.aov
Mail or fax a copy to Me Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 E Center Ave 3800 Banett Dr
Swannanea 28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
• Phone:828.296,4500 Fax:[phone] Fax:[phone] Phone:[phone]
. Phoen:910.4333300 Phone:[phone]
' - •
Washington Wilmington Winston-Salem
• . 943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27389 Wilmington 28405-2845 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] - Phone:[phone] Phone:[phone] .
(Retain a copy of tins form for your records)
Revised 05-2015