820325_Operator Designation Form_20190131

Mar 06 19, 11:45a P.3
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Animal Waste Management System Operator Designation Form
WPCSOCC '
NCAC ISA 8F.0201
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- Facility/Farm Name:
-4 ye 1�-C f�- s L —3
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92-- - County: _ ' �v Per•
• mit�: �ir��}Q��5. Facility 1D�:
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Operator in Charge(OIC)
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Name: V i C-i4 TVA Z
First .1.liddte L_aU Jr.Sr.err.
Cert Type/Number: oU Cc/70 . Work Phone: ( gr l tl z
et
Signature: • Date: r f I
"1 certify that I agree to my designation as the rotor in Charge for the facility noted.I understand and will abide by the rules and regulations
pertaining to the responsibilities se:forth in t5A NCAC 03F.0203 and failing to do so can result in Disciplinary Actions by the Water
Pollution Control System Operators Ccrt:fication Commission."
Back-up Operator In Charge(Back-up OIC) (Optional)
Name:
Pr-et Middle La r Jr.Sr.etc
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Cert Type;Number: Work Phone:
Signature: Date: •
ee tify that I agree to my designation as Back-up Operator in Charge for the facility noted.[understand and will abide by the rules and
regulations pertaining to the respcts:bilities set forth in 15A 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:
Phone F: I 11- ) I • 7j Faxtl:( 1J C ) c ) 57)75
C _ Date: I-3 l9
Signature: � �— J
(Owner or acthonzed ag
Mail,fax or entail she WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Email:certadmin(a)ncdenr.gov
Mail or fax a ropy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 E,Center Ave 3800 Barrett Dr
Swannanoa 2877E Suite 714 Suite 30i Raleigh 27609
Fax:[phone] Fayetteville 28301.3043 Mooresville 23115 Fax:[phone]
Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone]
Phoen:910.433.3300 Phone:[phone]
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Washington Wilmington Winston-Salem
943 Wa shincton Sq 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]
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• . (Retain a copy of this form for your records)
R:.•rsed of-2C t s
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