820494_Operator Designation Form_20190131

.. 0619, 11:54a p.11
Animal Waste Management System Operator Designation Form
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wPCSOCC
NCAC 15A 8F.0201
Facility/Farm Name: Y
Alms
Permit#: I7 if"S K.( nt 7 7 • Facility 1D#: '--�- T 1c7 County:
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• . . Operator In Charge(OIC)
n
Name: Vi rt C e rk I' G �'oNia Z •
First Middle La.er Jr.Sr.etc.
Cert Type!Number; A too C 7O. Work Phone: ( �11 )'7 9,l J I'7 a
Signature: 'f •
Date:
"I certify that I agree to my designation as the rater in Charge for the facility noted.I understand and will abide by the rules and regulations
pertaining to the responsibilities set forth in 15A NCAC O8F.0203 and failing to do so can result in Disciplinary Actions by the Water
Pollution Control System Operators Certification Commission."
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Back-up Operator In Charge-(Back-up OIC) (Optional)
• Name:
Firs! Middle Last pit Sr.etc.
•
Cert Type f Number: Work Phone: (
• Signature. Date:
• •"I certify that 1 agree to my designation as Back-up Operator in Charge for the facility noted.1 understand and will abide by the rules and
•
regulations pertaining to the responsibilities set forth in ISA NCAC OSF.0203 and;ailing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
•
Owner/Permittee Name: f—4.t+k -L5 12-C ! Rite A. 1-4,A(,S
Phone# �J: ( 910 ) h I ` "5?3 Fax :J If 0 ) 2 ' �t)7
Sigrtataare. - '_5 GvLJ� } " 7
Date: ! '1 I
(Owner or authorized age"!
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Mail,fax or.eaail the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Email:certadmin(tiinedenr.eov
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 CS Hwy 70 225.Green St 610 E Center Ave 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609 •
• Fax;828.299.7043 Fayetteville 28 3 0 1-5043 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.Flans Mall Rd
Washington 27889 Wilmington 2 84 05-2 84 5 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax;336.776.9797
Phone:[phone] Phone:[phone] Phone:[phone]
(Retain a copy of this fern:for your records; •
Revised 05-2015