800017_Other Agency Documents_20220107

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name: Q<}
Permit #:_v D
Operator In Charge (OIC)
Name: Al l
First
Cert Type ,/ Number:
Signature:
"I certify that I agree to my designation as the Operator 5A NCACt08F.0203 andte faihng to dolity socan resultan Disnd eipiinarytde Acbons by the Watery the rules and regulations
pertaining to the responsibilities set forth in
Pollution Control System Operators Certification Commission."
Back-up Operator In Charge (Back-up OIC) (Optional)
l I1 , s c
arte
Facility ID#: - I t County:
Jr. Sr, etc.
Work Phone:
RECEIVED/NCDED/DWR
JAN
WQROS
MOORESVILLE REGIONAL OFFICE
Date: 1 9-
Name:
First
Cert Type / Number:
Middle Last
Jr, Sr. etc.
Work Phone: (_
Date:
Signature:
les and
"I certify that I ag, ee to my designation as Back-up Operator 15A NCAC 08F 0203 r the facility
andifailing to do so can resultdin willabide
plenary Actions by the
regulations pertaining to the responsibilities set fort
h Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name:
Phone #: /0
Signature:
(Owner or autho
0
ed agent)
Mail, fax or email the
original to:
Mail or fax a copy to the
appropriate Regional Office:
WPCSOCC, 1618 Mail
Email:• certadmin( node
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
0
Fax#:
Service Center, Raleigh, NC 27699-1618 Fax: [phone]
l'.gOY
Fayetteville
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]
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]
(Retain a copy of this form for your records)
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 05-2015