820557_Operator Designation Form_20190131

:.:ar 2719,08:25a p.1
•
Animal Waste Management System Operator Designation Form
• .- WPCSOCC
NCAC 15A 8F.0201 .
;. r--- 89 c 7 'Facility/Farm Name: L-L-L
•
Permit#: t/ST2 T, Facility ID#: �- - •SS /County: i-- f�
'fir` Operator In Charge(OIC) -
• Name: gr_.ci 4,,it „,
• First Middle r/LLast Jr.Sr,etc.
Cert Type/Nit bey:.41h qG d r Work Phone:( 74' ) 34:5[—26//
l r
Signature: : P°'' 4 Z., /' '7� Dale: / 7/ �7
, s I certify.that I agree toy designationOperatorChargefacilityby g
-1.'5,5.,, fy Sr s m as:he in for Me facili noted.I understand and will abide 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.ere.
Cert Type/Number: Work Phone:( )
4'a'::"`. Signature: Date:
• "I certify that 1 agree to my designation as Sack-up Operator in Charge for the facility noted.[understand and will abide by the rules and
regulations pertaining to the responsibilities set forth in ISA NCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the
• Water Pollution Control System Operators Certification Commission."
OwnerlPerinittee Name: t - , ��
`,„ .' Phone 4: ( TO1 3k- 7 ii F #:( )
' `F Signature.:¢ rr``'l L-.[.0 , 8 -,1//F � - • Date: /3/-7I
(Owner or authorized aglSt.)
Mail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
original to: Email:certadminancdenr.aov
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh •
appropriate Regional Office: 209,0 US Hwy 70 2225 Green St 610 E Center Ave . 3800 Barrett Dr
rs,.. %i'" Swannanoa 23773 Suite 714 Suite 301 Raleigh 27609 '
.''ff= : : Fax [phone] Fayetteville 28301-5043 Mooresville 28115 Fax [phone]
'" • Phone:828._96.4500 Fax:[phone] Fax:[phone] Phone:[phone]
Phoett:910.433.3300 Phone:[phone]
' Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmington 2840 5-2 84 5 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone] "
(Retain a coin of this form for your records/
%'-t Revised Of.-7.015
.