310166_Operational Agreement_20210809

07-29-' 21 05:20 FROM- T-209 P0001 /0002 F-387
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name: RL Pickett Farm
Permit #: AWS310166 ]Facility ID#: 31 _ 166 County: Duplin
Operator In Charge (OW)
Name: David Bryan Pickett
First Middle LAN Jr, Sr, etc.
Cert Type / Number: AW/1998095 Work Phone: ( 910 ) 289-1433
Signature:
-_,<Q /.;----
'—. Date: 7/ZZ/L/
"I certify that 1 agree to my designation as the Operator in Charge for the facility noted. l understand and will abide by thc rules
and regulations pertaining to the responsibilities set forth in t SA NCAC 08F .0203 and failing to do so can result in Disciplinary
Actions by the Water Pollution Contrail 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 1 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 thc responsibilities sct forth in I SA NCAC 08F .0203 and failing to do co ran result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name: Claudette J. Pickett
Phone #: [phone]
Fax#: ( )
Signature: Qhorize . __ Date: 7/t-' ./ Z l
Owner or authorized agent)
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 8/2007