310237_OIC_20210311

RECEIVED
MAR 12 2021
NC DEQ/DWR
Central OffiCO
1
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name: CR Farms
Permit #: AWS3100237 Facility ID#: 31 - 237 County: Duplin
Operator In Charge (OIC)
Name: William M
First
Middle
Cert Type / Number: AWA 16363
Signature
Dotson
Last
Jr, Sr, etc.
Work Phone: ( 910) 298-4362
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 15A NCAC O8F .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)
First Middle Last 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 08F .0203 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name: Christopher E. Rhodes
Phone #: [phone]
Fax#:I
Signatur eKr or thou. aldrA/ Date: 3-3-2/
Mail or fax to: WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]
(Retain a copy of this form for your records)
Revised 8t2007