820487_Operator Designation Form_20190625

126/2019 8:38:12 AM WAMC Peds Clinic 910-908-2297 112
Carol Carroll Fax cover Sheet
Name; Carol Carroll
Phone;910-988-0233
Fax:[phone]
Email:[e-mail]
Fax Cover Sheet
Send to: Animal Waste Management System From: Carol Carroll
Attention: WPCSOCC Office
location: •
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Office Date: 26JUNE2019
location:
Fax number: 910-486-0707
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URGENT El REPLY ASAP Ei PLEASE COMMENT PLEASE REVIEW El FOR YOUR INFORMATION
TOTAL PAGES,INCLUbING COVER: i
Comments:
To follow is the Animal Waste Management System Operator Designation
Form for Kenneth Carroll with C&C Farms.
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CONFIDENTIALITY NOTICE
• This document may contain information covered under the Privacy Act, 5 USC 522(a),and/or the Health insurance
Portability and Accountability Act(PL 104-191)and its various implementing regulations and must be protected In
accordance with those provisions. Healthcare Information'Is personal and sensitive and must be treated
accordingly. If this correspondence contains healthcare information it is being.provided to you after appropriate
authorization from the patient or under circumstances that don't require patient authorization,You,the recipient,
are obligated to maintain it in a safe,secure and confidential manner. Redisclosure without additional patient
consent or as permitted by law is prohibited. Unauthorized redisciosure or failure to maintain confidentiality
subjects you to application of appropriate sanction, if you have received this correspondence in error, please notify
the sender at once and destroy any copies you have made.

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Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC ISA SF.0201
Facility/Farm Name: C, & l_. 11 1-5t`J +vi1"-
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Permit#: ,`,WS a0 y Facility ID#: 8 -1-1.37 County:
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Operator In Charge(0IC)
• Name: K t?.h n e >✓-P�_. D t-t<
, First Middle Las! Jr,Sr,arc.
Cert Type I Number: AN 44.1ti`(ILL4 crg'6,94.1" Work Phone:( 10 ) gS .749 1
Sig�iattlr AM" ' Dater to f o1.57 e
"I certify that 1 agree'to my designatioh as the Operator hi 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) (Optional) •
Name:
first Middle Last Jr,Sr.ro.
•
• 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.'l 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."
Owner/PerMittee Name: )1 7 1
Phone#:(q[O) goo �I � - Fax#:( _
:gnatur• . Date:
• ( •meter authorize agent)
�/��"JZO/c�
f
='J Mall,fax or entail the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:919.715.272E
. origitral to: aflt certadlinin ncticnr.eov
•
Mall or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 F.Center Ave 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax:828,299,7043 Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:[phone] Fax;910.486.0707 Fax:704,663.6040 Phone:919,791,4200
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:252.946,9215 Fax:[phone] Fax:336;776.9797
Phone:252,946,6481 Phone:[phone] 191one:336,776.9800 r"
(Retain ca copy of this form for your records)
Rovised 05.20)5