820681_Operator Designation Form_20200410

Apr, 12. 2020 10: 51 PM WEEKS FARM No, 6363 P. 1/1
Animal Waste Management System Operator Designation Form .
WPCSOCC -
NCAC 15A 8F.0201
fi F //'t't%4,� / ✓4 -5 J, v C-' ,ir•e`
.acilaty/Ti~aren Name: �4 . r .
Permit#: ,j iTQ&60/ Facility ID#: p. -b 7 County:." .ri" —'-'-
..
'i'_.yperator I harge(OIC)
:1'„, ;'Tame: I !1r4.a �-'
first /Cle" Middle Last Jr,Sr,etc.
Celt Type/Numb •: 6�1( 9 Work Phone: (90 ) F"—?,77.
-Signature: _ je Date: "7/040 e-cp
='' ''I 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
',!a.'s ,:." pertaining to the responsibilities set forth in 15A NCAC 03F,0203 and failing to do so can result in Disciplinary Actions by the Water
•• `�`'`�''h,'i'Pollution Control System Operators Certification Commission." ,
" hack-up Operator In Chargé(Back-up OIC) (Optional)
:i4ame:
First Middle Last Jr,Sr,etc, '
- -ert Type/Nt?rlibri r: Work Phone: ( )
..,'•,•y ', •Nignatture: Date.
:I-certify that I agree to my designation.as Back-up Operator in Charge far the facility noted.I understand and will abide by 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 .
;.`relater Pollution Control System Operators Certification Commission."
-1:< . .Oivner/Peroaittee Name: feels 1 �— c---- •'
1:f =�.x' .Phone#' Fax#: (9ll.� ) 'Qi 7 'g 7 ,
•
.,-StgYlature: - — :Date: cf •0 c7
(Owner or authorized agent) •
Mail,faz or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
•
7gtnal to: Emil;certadl nl( )nedenr.tiny
`r Fr' ::lad or fax a copy to the Asheville Fayetteville Mooresville Raleigh
` 2090 US Hwy 70 225 Green St.
'�'f';t�J.;'� rr��rojlriate Regional Office: 610 E Center Ave 3800 Barrett Dr
_ Swennanoa 28778 Suite 714 Suite 301 Raleigh 2'7609
Fa$:828.299.7043 Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:828,296,4500 Fax:[phone] Fax:704:663.6040 Phone:[phone]
-' Phoen;910.433,3300 Phone:[phone]
Washington WIlmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
°";;` Washington 27889 • Wilmington 28405-2845 Winston-Salem 27105
y''t" Fax:[phone] Fax:[phone] Fax:'336.776.9797
,;:< . Phone:[phone] Phone:[phone] Phone:[phone]
(Retain a copy of this form for your records)
:1-:.Revised 05-2015