820352_Operator Designation Form_20200507

820.02:16p BanvickAgselvices 9105900074 p.1
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A SP.020I
•
Facility/Farm Name: ,-- r
"
2e?rlit#tr.: p11tS P.0,3 Facility Inn: b) rr S'
3J County: 74 uc�.
• .,.'• Operator In 5harge(OIC)a �1oi
Marnne `t �J7�' �j
First
Middle r.,;--:
A4� - 166 ga 947 Jr,Sr.etc.
CurtType/NumWork Phone:(1I9 , ->S -2ll7
Signature: Ij •
Date: S�j Zcs-2_U
-I certify that I agree TO my designation^s:n tip- -_ e Operator in Cha.gi for the facility noted.I 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 c n result in Disciplinary,Actions by the Water
Pollution Con-ol System Operators Certifcation Commission.-
r`
P O1-u ac
Back-up Operator to Charge(Back-up
!l ',.•', C) (Optional)
Name:
Fin; Middle
Lsar , Jr.Se.etr.
Curt Type I NLm6er:
Work Phone:( 1
Stgnartre:
Date:
T*, -i eertify that I agee to my designation as Back-up Opera:or inCharge for the facility noted_I Itrderstand and will abide by therutes and
= regulations pertaining to the responsibilities set forth in 15A NCAC 03F.0203 and failing to do so can result is Disciplinary Actions by the
Water Pollution Conuto1 System operators Certification Commission"
,,
Owner/Permittee Name: At t ..r5`c75si*--)
• Phone Y f 7r J • .:Zq
I`Ill'il _
Signature:
(Owae:o:authorized agent) Date: Z�zJ
:'i1 eLluif,faxorerrrail the VS'1'CSOCC, IGIB �4at]Service Center.a,;t: ' a•ig:nat to. Raleigh:SIC 27699-161R Fax:[phone]
zro .,.t,;-:; Email:certadmsn(?uncdenr.00v
Mall or fax a copy to the Asheville
Fayetteville
appropriare Regional Office: 2090 US H� y 70 225 Green Si 10o:Centeret Raleigh
Swannanoa 28778610niE Ave 3800 h 276 9Dr
Suite 714 Suite 301
Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fay:
91 .571.
Phone:[phone] Fax:[phone] as:915,5,1.4718
Fax:[phone] Phone:[phone] Phoen:910.433.3300 Phone:704,663,1699
Washington Wilmington
i 943 Wshin imn SqMall 1 450 W Hanes v
g 2,Cardinal Dr 450 W.Hanes ivlall Rd
Washington 27889 Wi rtineton 28405-2845 Winston-Sal=27105
"'-`''` : Fax:[phone] Fat:310 354 2504
Phone:[phone] Phone:910.796,72I5 Fax e3.77w9798
Phone::[phone]
(Amin a copy of lM3f01rn for your records)
3eCizn105.2015
g,.

Jun 21 19.01:21p p.1
•
•
Animal Waste Management System Operator Designation Form
WPCSOCC
• NCAC 15A 8F.0201
Facility/Farm Name: 'J CCO t.J T
LA i •
Permit#: .} Z Facility at - S Z County: S1t sv,
Operator In Charge(OIC)
Name: Azlti, A . 6`'s4--`tC_
Firs, Middle Last Jr,Sr.etc.
Cert Type/Number: "(
t�t a' /AA)
Work Phone:( ?/D ) a''?/4 f j
Signature: 67,44 ,,n 41.6
(l t Date:
"I certif,,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
Pollution Control System Operators Certification Comtnission."
Back-up Operator In Charge(Back-up OIC) (Optional)
Name:
First :'rlidale Last Jr.Sr,etc.
•
Cert Type I Number: Work Phone:( 1
Signature: Date:
"1 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 pertaining to the responsibilities'set forth in I5ANCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the
- Water Pollution Control System Operators Certification Commission."
�
Owner/Permitiee Name: � f� 7 yr,r/)'•�:'w r7 �� e
Phone#: O ) a6V1 ` °� Fax#: ( )
Signature:r .�� r Date:
(Owns•or au 14 rtzcd :e
. iYlail fiaxor email the WPCSOCC: 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
ortgu:al to: Email:certadmh a7,ncdenr.gov
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
Swaonanoa 28778 Suite 714 Suite 301 • Raleigh 27609
•
• Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:[phone] Fax:[phone] 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 28405-2845 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
(Retain a copy of this form for your records)
•
Revised 05-20t s