820718_Operator Designation Form_20190807

"28 19.01:55p p.1
•
Animal Waste Management System Operator Designation Form
WFCSOCC
• NCAC 15A 1311.0201
•
•
• .• Facility/Farm Name: 6—er-C 5 ;
Permit 1l: /t4 ) c'2 191)c Facility 1D#: - 71ff County: it—.pJv-,
Operator In Charge((MC)
Name: i vt : o '-.
• Firer ,i�, flddlc -7 Lost Jr,Sr,etc.
Cart Type;Number: j�W Jt / ' V W ork Pllone:( I1 ) f7� }29 f
Signature: • Dale: P~ --ty
"1 certify that I agree to my designation as the Operator in Charge for the facility noted.]understand and will abide by the odes and regulations
pertaining to the responsibilities set forth in 1 SA NCAC BF.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 ,tftdrfie Las; 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.3 understand and will abide by the rides and
regulations pertaining to the responsibilities act forth in 15A NCAC 0SF.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
•
Own erlPermittee Nagle: (r—rl C Sw u f (JZ✓rr if a oil^'•
C Pbone'I: " i i S7a
Q— ) 7.7
Signature. per*.., Date: r- 7'/7
Owner or authorized agent)
Mail,fax or email the WPCSOCC, 1613 Mail Service Center, Raleigh,NC 27699-1618 Fax:919,715.2726
• original to: Email:certadmin( nsdenngov
Mail or fax a copy is the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US lltvy 70 225 Green St 61D B Center Ave 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
• Phone:[phone] 111275:.'9110.486.0707 Fax:[phone] Phone:[phone]
Phnen:910.433.3300 Phone:[phone]
•
Washington Wilmington Winston-Salem
943 Washington Sq Mali 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]S1 Phone:910.796.721S Phone:[phone]
(Retain a copy of this form for your records)
Rc»xJ e5.2015