820502_Operator Designation Form_20190131

06 19, 11:45a p.2
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC I SA SF.0201 .
Facility/Farm Name:
L..'-4 year �-
���F �1 S J t Sci"+
Permit�: t 11"? .��t���`� Fatality IDS: ��--�t/�" County: �-
Operator In Charge(OJC)
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Name: i• ,n L en 1 - �iNa Z (1
Firs! Middle Las' .1.Sr,eic.
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' Cert Type/Number: 'Pt /CO Cr 7G Work Phone: t : ..
� 1Signature:
"i cert:i;.'that I agree to my designation as the rator in Charge for the faeiiiy noted.:understand and will abide by the rules and regulations
pertaining to the responsibilities set forth in L5A 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 O1C) (Optional)
Name:
•
Finer Middle Lear - .P-.Sr,err. -
• Cert Type I Number: Work Phone:(
Signature: Dare:
"I certify that I agree to my designation as Back-up Operator in Charge for the facility noted.I understand and will abide by the rules and
regulations peraining to the responsibilities set forth in l5A 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: ke-4,t4C �v`5 U-G 177 A A. i'4,ILdV
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Phase f 9I0 1 � !G 2' 3� f 3Fax#: ( iI° 1 c - �D7� -
Signature: -':— Date: I '3 1-1 f
(Owner or authorized ag
Mail,fax or email the WPCSOCC, 161 S Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Email:certadmin(atncdenr.zov
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 22,5 Green Si • 610 E Center Ave • 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] ' Fayetteville 28301-5C43 . Mooresville 28115 - Fax:[phone]
Phone:[phone] Faa:910.496.0707 Fax:[phone] Phone:[phone]
Phoen:910.433.3300 Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W. I-lanes Mall Rd
washing:on 27SS9 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)
Rtvlsad 05-20t 5 -- .