820475_Operator Designation Form_20200424

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Animal Waste Management System Operator Designation Form ,:v.:(
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W1 CSOCC r'!'::R3i. r,';
NCAC ISA 8T.0201 i; :,Rr,�;
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Facility/Farm i Name: �C=f°�s 1'
Permit;: tl- a YI . Facility ID#: 0- - 9Z County: ` — 4c :45�-• •_%
Operator In Charge(OIC) ;_i'Vt 11„' y
Name: e V1 o..s',On r
Fla( Middile Last Jr.Sr etc,
Cert Type/Number; ) 1 Work Phone;(C-S - ).-k -f 'g7
Signature:
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"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 ISA NCAC 03F.0203 and failing to do so can result in Disciplinary Actions by the Water -z srR,'?q t: t`'
Pollution Control System Operators-Certification Commission." „�._il ;x,•,
Backup Operator In Charge(Back-up OIC) (Optional) ,
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Name:
RIM Middle Lea_ Jr.Sr,eta '
Cert Type/-Number: Work Phone:( ) - - - ,
Signature: Date: r' `'
"I certify that I agree to my designation as Beet:-up Operator in Charge for the facility noted.I understand and will abide by the rules and : :r.
regulations pertaining to the responsibilities set fork in 15ANCAC 03P.0203 and failing to do so can result in Disciplinary Actions by the
Waterpollation Control System Operators Certification Commission."
OwnerlPer tlttee Name: b Q I}t1 Lr.,' Y1
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Phone: .. �� Fax#:'(°I0) i5L7.--` 4 15 t? -. .iT
Signature: ��',�-�� Date: 4--i ' � l ,,'f:'
(Owner or authorized agent) :;:••.°,+
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fbfalt,faxor email the WPCSOCC, 1618 Mail Service Center, Raleigh,:tiC27699-161S Fax:[phone]
originate,; Email;cartedrninrfflncdenr.trov
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Mall orfax a copy to the Asheville ,Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 B Center Ave 3800 Barrett Dr
Swar.nenoa 28773 Sufic 714 Suite 301 Raleigh 27609
Fat;823.299.7043 Fayetteville28301-5043 Mooresville28115 Fan 919.571.4718 -i
Phone:823,296.4500 Fax:[phone] Fax:704,663,6040 ' Phone:919,791.4200
Phoen:910.4333300 Phone:[phone] y`t t ..
Washington Wilmington Winston-Salem =s`i;'•=
943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmington 2.8405-2845 Winston-Salem 27105 =
Fax:[phone] • Fax:910,350?004 Fax{336.776.9797
Phone:[phone] Phone:[phone] Phone:336,776,9800
Win!a cope of riffs form.for your records!
Revised G5-2015
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