820470_Operator Designation Form_20200424

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Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F.0201
Facility/Farm Name: tas •
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Permit#: f'Ih.S g.2 6 y 20 Facility ID#: r - / x County: .✓7/ v ,...,
Operatoro In Charge(OIC) 'I
Name: Zak ,i,�l�e b ey.i.SDi
First dlyddle Last Jr,Sr,etc,
Cert Type/Number: 0 g"/ /7 Work Phone:(Z 2- ).S"[PP-/ g7
Signature; 4101...tri /:„L Date: 7 2el-2e7
"[certify that I agree to ray designation as the Operator in Charge for the facility noted.I understand and will abide by tho cults and regulations
pertaining to the responsibilities set forth in 1SA 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) (Optional)
Name:
nut bfrddle Last• It Sr etc
Cert Type/Number: Work Phone:( 1 I
1
Slgnatrrre: Date:
•
•'I certify that I agree to ray designation as Back-up Operator in Charge fertile facility noted.I understand and will abide by the rules and i
regulations pertaining to the responsibilities set forth in 15A NCAC 08P.0303 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
1 •
Owner/ ermitfee Name: t)Q of C' p'I t 1v 1 '
1
Phone#: `lq-k D Fax#:(ql O) Sta- 0 Li-6 b
Signature: Date: "Z 20 2 f
(Owner or authorized agent` (,,
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:Mail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:S.19.715.2726 i
original to: Email:certadmin)ncdenr.gov t
t
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh t
-_: appropriate Regional Office: 2090 US Eery 70 225 Green St 610 E Center Ave 380013arrett Dr
Swannanoa 29778 Suite 714 Suite 30I Raleigh 27609
Fax;8Z8,299.7043 Fayetteville 28301-5043 Mooresville 23115 Fax:919,571.4718
Phone:[phone] Fax:910,486,0707 Fax:704.663,6040 Phone:[phone]
Phaen:910.433,3300 Phone:704.663,1699 1.
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105 , `li
Fax:[phone] • Fax:[phone] Fax:[phone]
Phone;252.946.6481 Phone:[phone] Phone:[phone] h.
lRetuin a copy of this form records) 1'
Etsvi5er105-20J5 1-',
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