820698_Operator Designation Form_20190610

10 19,03:42p p.1
Animal Waste Management System Operator Designation Form
' PCSOCC
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• NCAC15A8F.0201
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exttAft
Facility/Farm Name: 0.,..U.SL-1/L.— (ii)LeVU 1
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Permit ; t'1(,O5'��� �g Facility 1D11-: . •JD 2 County:
Operator In Charge(OIC))� /
Name: )(0 bt,' t L-G k7$A 9
First 4lindle Last Jr.Sr.etc.
Cert Type!Nw er: f t 9 rr.2_ Work Phone:( ��� �/7 7/ -•
•
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Sigtlaltn e: Date a-
"I certify that I agree to my designed' n as t .Operator in Charge for the facility noted.1 understand and will abide bythe rules and regulations
pertaining to the responsibilities sett ol, in 15A NCAC 081'.0203 and railing 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 Len Jr,Sr,etc.
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 15A NCAC OSP.0203 and failing to do so can result in Disciplinary Actions by the
• Water Pollution Control System Operators Certification Commission.- -
Owner/Permittee Name: •
/`U �f 4 74-/' {ter yK�s�
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Phone ti; ( 9fa ) f —77/S _ Fax#:( , )
• Signature: -' "/I Date: +l--/e7—`7
(Omer o authorized agent)
ZJ
Mail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax: [phone]
original to: Email: certadmin tiinedcnr.trov • •
Mail or fax a copy 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 714 Suite 30] Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone]
Phnen: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:[phone] Fax:336.776_9797
Phone:[phone] Phone:[phone] Phone:[phone]
(Retain a copy of this form for your records)
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