820403_Operator Designation Form_20190614

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Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A SF.0201
• Facility/Farm Name: I2`' C�
Permit g:AsISS,10 3 Facility ID#: $cfe-1--' County:
Operator In Charge(O/ICC))1 f
Name: t 6' y / ►jrv�t�s ��oLo,%�`
First Middle Les( Jr,Sr,etc.
f
�J- ! 7%d:a Work Phone: (/d) -<1 7- S I S�l
Ceti Type/N ber: -� (
s tj —/' 9.
Signature: - Date: tt 7
"I 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
Pollution Control System Operators Certification Commission.-
Back-up Operator In Charge(Back-up OIC) (Optiona)
Name:
Fast diddle Lest Jr,Sr,etc. •
• Cert Type/Number: 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 pertaining to the responsibilities set forth in J 5A NCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
Owner/PermitleeName: -et
Phone#: ( C/O) • 7 ' 5/ y Fax#:( )
Signature.- / e. l
%y
ier or autho d agent)
Mail,fax or email the WPCSOCC. 1615 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Entail:certadminfr/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 Ate 3800 Barrett Dr
Swannanoa 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 ca copy of this form for your records)
• ' Revised 05-2015