820406_Operator Designation Form_20190131

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Animal Waste Management System Operator Designation Form
WPCSOCC
• NCAC 15A 8F.020]
• FacilitylFarm Name:
xe g
Permit n: P1V ?2- 4-47 Facility 104: 2--76 County: S ,f-
Operator In Charge(OIC)
•
1 n �
Name: , i C 2A prla 2 '�
First Middle Last Jr.St.etc
'Cent Type/Number: ' /Un 70 Work Phone: ( "l1 ) 92 /1)
Signature: Da;e: /,31 1 7
"I certify that I agree to my designation as the razor in Charge for the facility noted.i understand and will abide by the rules and regulations
pertaining to the responsibilities set forth in l5A 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:
First ,lfrddie • Lest J:.Sr.etc.
Cert Type/Number: Work Phone:(
Signarrre: Date: •
• I cer..ify that I agree to my designation as Back-up Operator in Charge for the facility noted.I understand and wiii abide by the rules and
. regulations pertaining to the responsibilities.set forth in ISA NCAC OSF.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission." --
• n
Owner/Permittee Name: �G r {}e . �- U�. b n
`r 1"1��.
Q / 1 �e
Phone K: ( 9!0 1. ���•' 3� 3 � Fax ( `/D } ,r 7c
Signature: 61Date: 1 3 -/ 1
(Owner or authorized agent
Mail,fax or email the WPCSOCC. 1618 Mail Service Center, Raleigh,NC 27699-16]$ Fax:[phone]
original to: Email:certadmin(2ncdenr.gov
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
t. ; appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 E Center Ave 3500 Barrett Dr
Su•annanoa 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 Washingtor.Sq Ma:l 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 o/t/tis,;orm for your reCO]'CS)
Revised 05-2055