820290_Operator Designation Form_20190614

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Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC I5A 8F.0201
Facility/Farm Name: 4- Po)t-rru
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Permit a: ,`j$�� q� Facility ID#: a county: •
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' Operator In Charge(OIC)
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Name: DArry, / 10.,,taf J-laii/J
Firs, Middle Last Jr.Sr etc.
Cert Type/Number: J / 7/0 Work Phone: ( 9/e) s�7-_S ,I l
Signature:, •fLJ yC a- ' Date: - -6 •.-)t{- �- - - -- -- ----- --
"I certify that I agree to my designation as the Operator in Charge for the facility noted.1 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 In Charge(Back-up OIC) (Optional)
Name: , •
Firs: Middle Last Jr.Sr,etc.
:` ':. Cert Type!Number: Work Phone:( 1
. Signature: - Date:
"1 certify that I agree to my designation as Back-up Operator in Charge for the facility noted.1 understand and will abide by the rules and
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regulations pertaining to the responsibilities sct.forth in 15A NCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the
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' Water Pollution Control System Operators Certification Commission."
O►►ner/I'ermittee Name: Di`ftyj 4- v,,, )1Ui•t;i-) •
Phone #:( 7 r
/6) .51 7' S. `1) Fax#:S )
Signature Cry �� Date: ,} --f j��
inner or an zed agent)
Mail,fax or entail are WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax: [phone]
original to: Email: certadmin cnr.ncdenr.gov
__ Mad or fax a copy to the Asheville Fayetteville Mloorest.ille • Raleigh
` -{ appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 L'Center Ave 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite-301 Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 Mooresville 28315 Fax:[phone]
Phone:[phone] Fax:[phone] • Fax:[phone] Phone:[phone] •
Phoen:910.133.3300 1'hone:704.663.1699 -
Washington . Wilmington Winston-Salem
943 Washington Sy Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
• •Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
Fax:[phone] Fax:[phone] - Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone] • •
(Retain a cops'of this form for your records).
Revised 05-2015