820693_Operator Designation Form_20190614

: 1719,08:27p p.4
.., Animal Waste Management System Operator Designation Form
• - WPCSOCC
• NCAC 1SA 8F.020I
Facility/Farm Name: 4'bt4XLA.A_ is ,OS r C►\-c re_ If ,
1,��.r�',I` a
Permit#: i"`WS �0�3 Facility iD#: $Q -�093 County:
Operator 1n Charge(01C) '
, ,Naive: -- 1 ' Jl�nea.cr //OL..,✓
• First Middle Lost Jr,Sr,etc. .
. Cert Type/Number: 4i4 / 6 7/0 Work Phone:(�r/6 ) S 7--.9 l El'1
• /1,_ i -r1
. ,ta x , � s -,f y !
Signattn'e:4 -��%Z�� N �4 71 0 Date: • 6 — 9
t/
"1 certify that l agree to my designation as the Operator in Charge for the facility noted.1 understand and will abide by the rules and regulations
, pertaining to the responsibilities set forth in 15 A 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 MC) (Optional) '
Name:
First ) - .Middle Last \ Jr,Sr,etc.
:,,�," Cert Type!Number: Work Phone:( 1 .
Signature: Date:
- • "1 certify that i agree to my designation as Pack-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 15A NCAC 081.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission." - - -• •
-
:, /7
- Owner/Permitter Name: � •-�• e W; ,3;t9 S 1'.--<. LL• C
• - Phone tr:(I� ) . 7—��• l Fax ( )
SigranfreC
Date: —i r `/ y •
(Omar or au r razed agent) L
malt,-fax or entail the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax:[phone]
•j,r,, orir inert to: Email:certndminOncticnr.aov
• •- , Maii or fax a copy to the. • Asheville Fayetteville Mooresville Raleigh -
-��F�'_' appropriate Regional Office: 2090 CiS Hwy 70 225 Green St 610 E Center Ave 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite 30l Raleigh 27609
Fax:[phone] 'Fayetteville 28301,5043 Mooresville 28115 Fax:[phone]
Phone 828:296.4500 Fax:[phone] Fax:[phone] Plwne:919.791.4200
Phocn: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]
• Phone:[phone] Phone:[phone] Phone:[phone]
•' (Retain a cops'oftltis•/oi in for your records)
f:erfsed D5 2015 - - - .. - - • -