820458_Operator Designation Form_20190910

. 14 19,05:14p Barwick Agservices • 9105900074 p.2
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Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F.0201
Faciiit}/Farm Name: f!a x /.,. r/t4/S�} ra"'", i`.c, -
Permit#:_f7 ,d S �'Z Q /c4 Facility III#: r /7- 171-17.County: •rS•`-N.
Operator In Charge(OIC)
Name:_ilak J(xrl� S
. First , ' /Midddle G Last Jr,Sr.etc. ;.
Cert Type/Num' ram! r ITS! Work Phone: ( 9r-v ) Jdf 1 1 f8W•
Signature: Date: g.l lo! ( 9
"I certify that I agree to my designation as the Operator in Charge for the facility noted.I understand and wilt abide by the rules and regulations
pertaining to the responsibilities set forth in 1 5A NCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the Water
Pollution Connol System Operators Certification Commission.'
. Back-up Operator In Charge(Back-up OIC) (Optional)
I Name: DP nit 5-- r Gp - ,
First Middle •
�? Last Jr.Sr,eta
•
- Cert Type/Number: .40 7 i8-6 I f Work Phone: (�7 1-0 1 -SS0_5'5-3-5
.�� 5
�3 �5
. , Signature: Date:
"I certify that I anree to my designation as Back-up Operator in Charee for the facility noted.I understand and will abide by the rules and
regulations pertaining to the responsibilities set forth in 15ANCAC OSF.0203 and failing to do so can result in Disciplinary Actions by the
- Water Pollution Control System Operators Certification Commission."
O t1'I fL/'`- ��`�
OavnealPermittce Name:
•
Phone#: ( AO ) . I — /3Th _ Fax#:( ) •
. Signature: Date: - 7-/12 7,1
(Owner or authorized agent) 4, ,
Mail,fax or email the W PCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone] .
original•to: Email: certadmini ncdenr.uov
Mail or fax a cope to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 225 Green St - 610 E Center Ave 3300 Barrett Dr
Swannaroa 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 05-21)15 ,