820529_Operator Designation Form_20190129

0719,05:54p p.1
• Animal Waste Management System Operator Designation Form
WPCSOCC •
NCAC ISA 8F.0201
Facility Farm Name: Di�vn`3 Vt
1
Permit 4: AkAri i v Z 0 S 2 9 Facility ID#: 'z - 5 aY County: . ' '--
a ; Operator in Charge(OIC) j
Name: 6 t 4l L6''''1. Pia-- k
F-S; Middle Last Jr.
Sr,as
Cart Type!Number:AIM 10O G 6 63 Work Phone:((i/V ) 3i_i - L1 i q
Signature: =— £ 2',� (J,� Date: /J 7--/ 7
":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 I 5A NCAC O8F.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,etc.
Cert Type/Number: Work Phone: ( )
Signature. Date:
"1 cenify 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 pertaining to the responsibilities set forth in l5A NCAC O8F.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission,"
O►vneriPerrnittee Name: AG ta(j PUus 5
Phone#:f /0 } .3 S"c` I d I (� Fax#: ( )
Signature: c.J/ D ,� /r f,' �C��/rf
Date: '
(Owner or authorized agent)
•
• Mail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Email:certadmini ncdenr.gov
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 E Center Ave 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 'Mooresville 28115 Fax:919.+71.4713
Phone:[phone] Fax:910,486,0707 Fax:704,663.6040 Phone;919.791.4200
`I•' • Phoen:910.433.3300 Phone:[phone]
Washington \Vilsnington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mali Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:252.946,6481 Phone:[phone] Phone:[phone]
. (Retain a copy of this form for yourrecords)
Revised 05-20I5
I