820385_Operator Designation Form_20200424

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220,04:29p BalwickAgservices 9105900074 p.3
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Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC I SA 8F.0201
Facility/Farm Name: at 11 Q 1
Permit4: Pfli45e 2 (1 S!J Facility iD#: e 2, - 33,cCounty: -lea c`-).
Operator In Charge(OIC)
;,,.,; Name _ ®�j� ELT �1 1y Y�
First Middle Last ii Sr.ere.
Cert Type/Number: Q Work Phone:(i� 2- )Sb2J-1 S '
Signature: (,.--- Date: 7'2 2
"I certify that!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 Commission."
Back-up Operator In Charge(Back-up O1C) (Optional) '
Name:
Foxe A-fiddle Last_ JP.Sr ere. ,
Cert Type/Number: Work Phone:( )
4
Date:
, • Signature.
_ "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 I5A NCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission." I
Owner/Permittee Name: l)Q O..If 1 (,. 1""
Phone#: C©� i' V U Fax#: (q'I O) O l 61 l5 b
Signature: -'''-. Date: 4—24—Z0
-29
{Owner or authorized even E
:Wail,fax or email Me WPCSOCC, 1618:Wail Service Center, Raleigh,NC 27699-1618 Fax:[phone]'726
original to: Finatt:certadmin(@ncdenr.gov
Mail or fax a copy to the Asheville Fayetteville
Mooresville Raleighi
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:828.29%,7043 Fayetteville 28301-5043 Mooresville 28115 Fax:919,571.4718
Phone:828.296,4500 Fax:[phone] Fax:[phone] Phone:[phone]
Phoen;910,433,3300 Phone:704.663,1699 i.
Washington Wilmington Winston-Salem •
943 Washington Si Mall 127 Cardinal Dr 450 W,Hanes Mall Rd •
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105li
Fax:[phone] • Fax:[phone] Fax:336,776.9797 L
Phone:[phone] Phone:[phone] Phone:[phone] c
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literati:a copy ot•this form for your records) c
n55:ie 105-2015
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