820667_Operator Designation Form_20190131

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• Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC15A8F.0201
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Facility/Farm Name: Lye ''"`f `r
;; Permit#: `f SIO at Facility 1D#: Y.---- YCa,/ ,County: ��- -ter.-,
Operator 1r Charge(OiC) • ,
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Name: " i A Lin n i"irYG.2 S''
First Middle Leez Jr.Sr etc. . .
. ss Cert Type l Number: i)A /0U 6T-0 Work Phone:( /f) )7 c 2 r 1 Z
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Signature: ' • Date: 3/'1 7
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"I certify that]agree to my dbsignation as the rator in Charge for the facility noted.I understand and will abide by the rales 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 O1C) (Optional)
Name:
First Middle Last Jr.Sr,etc.
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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,I understand and will abide by the rules and ,
• regulations pertaining to the responsibilities set forth in I SA NCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the '
Water-Pollution Control,System Operators Certification Commission" .
•
t cs•. F �.
OwnerfPerrnittee Name: 4-6_ e' . v1 i!iLL Ax, ». het.,✓-,1E- ? • .
Phone#: ( `'I 1v' ) 7`1 - -Y) .7 Fax#:( 1/6 ) cif " o 7c
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Signature: (// � , Date: )-g) rt
(Owner or authorized as ._ ,
' rt.,.., Mail,fax or email the • WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fat.919.715.2726
original to: Email:certadminOncdenr.eov
6:.+,• Mail or fax a ropy 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 7i4 = -'Suite 301 Raleigh 27609 '
Fax:[phone] , Fayetteville 28301-5043 Mooresville 28)15 Fax:[phone]
Phone:[phone] Fax:[phone] Fax:[phone].- Phone:[phone] .
' Phoen:910.433:3300 Phone:[phone]
Washington Wilmington Winston-Salem, ,
•943 Washington Sq Mall i 27 Cardinal Dr 450 W.Hanes Mall Rd - ,
:;".1., Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
",.•"==?c Fax:[phone] Fax Fax:[phone]
:F;?:M. Phone:[phone] Phone:[phone] Phone:[phone] '
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- (Retain a copy of this form for your records) . •
. • 2evued052015 • .