820681_Operator Designation Form_20191117

Nov. 21, 2019 3: 09AM WEEKS FARM No, 6286 P. 1/1
Animal.Waste Management System Operator Designation Form
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- wFCSoCc
• :<;;6.'.' NCAC ISA 81'.0201 •
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Facility/Farm Nan1e: ... W k
et 4 , ) .• g`-►voS ..
Permit#: blg1 to L Y! Facility ID#: - J�s'I County: 6,ff y
'' Operator In Charge(OIC) .
N•ae: 9 I> <J
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First bale Last • Jr,Sr;'ere. -
Cert,Type/Number: .Ur+ ' • /G I D. Work Phone:( 91`i ) 3/Q.-q.5 7
• . • Signature: Date: //- 7/9
= ' :;'_• "I certify that I agree to my design on 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•15A NCAC 081 ,0203 and failing to do so can result in Disciplinary Actions by the Water
'' ';;' , Pollution Control System Operators Certification Commission" ,
. Backup Operator•In Charge(Beek-up OIC) (Optional)
Name: -
First . rltiddle ' Lint Jr,3r,etc.
C;ert Type/Number . . T 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 I5A_NCAC 08F,0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System-Operators Certification Commission."
A' Owner/Pertnittee Name: .. _ CGS' -
. Phone##'( f g_. Fax,#'(cf/O). 87/ W64 . .• -
• 1 Signature.: 41 ,. . Date: // .1
(„ er or authorized agent)
Maio fax or entail the WPCSOCC, 1.618 Mail Service center, Raleigh,NC 27699-1618 Fax [phone] _ ,
original to: Jiiail aR-taii ti ncalet,i-.aov •
1.`-,;°f� ': Mail or fax a copy to tire. Asheville Fayetteville. ,Mooresville Raleigh
'`- 2090 US H 70 225 Green St 610 E Centex Ave 3800 Barrett Dr
- `;;;;.,. as�prvpriuteRdgiontaf Office: u'Y
Swanuanoa 28778 Suite 714 . Suite 301 Raleigh 27609
- Faxs 828:299,7043 ' Fayetteville 28301-5043 Mooresville.28115 Fax:[phone]
Phone:[phone]sto • Fax:[phone] Fax:[phone]o Phone:919.791.420o
- Ptton: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 .
• Fax:.[phone] Fax:910,350.2004 Fax:[phone]
.. e4.'. ' PhoJne:252:946:6481 Phone:[phone] Phone:[phone]
- (Retain a copy of this form for your records) .
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