260007_OIC_20210214

QEQIDWR
Name:
Facility/Farm Name:
Permit #:
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
&flair/ rartr\--
Srditr
116;62 G)&,) Facility ID#: �` - ( County:
FL?4 2021
WQROS
PAYSTElfildEREVOMOFFICE
Operator In Charge (OIC)
First . Muddle Last
Cert Type / Number:
Signature:
227?
i/h1
Jr, Sr, etc_
Work Phone:
Tie ) es-0 -4 q7 ,
Date:
"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
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."
Back-up Operator In Charge (Back-up OIC) (Optional)
Name:
Jr, Si; eta
First
Middle
Last
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 I5A NCAC 08F .0203 and failing to do so can ie iu1t in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name: / 4 76i. /
Phone #: (l/o) 3
Signature:
(0 f or autho
Fax#:
Date:
Mail fax or email the
original to:
Mail or fax a copy to the
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Email: certadmin( 3ncdenr aov
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayettevitte
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phoen: 910.433.3300
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Fax: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Banett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 05-2015
(Retain a copy o_f this form for your records)