640074_Compliance_20220214

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F A201
Facility/Farm Name: 4%19 Bo
Permit # : _ Facility IDS# :
? - � County :
Operator In Charge ( OIC )
Name : /3h4�1t ?/ /
First Middle Last Jr, Sr. etc.
CertType / Number : 4üh14w /cjD3A ' Work Phone : ( 27Z ) zcc' 7 ? 3
Signa tu re: j l_ / _ Da Ic: 202
7
" 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 I SA NCAC 08F .0203 and failing to do so can result in Disciplinary Actions by the Water
Pollution Control System Operators Certification Corn miss ion."
Back-up Operator In Charge (Back- up OIC) (Optional)
Name :
First Middle Last Jr, Sr, etc.
CertType / Number:_ Work Phone:
Date:
" 1 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 OSF .0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission ."
Owner/Permittee Name : R?LAfC/ E'e'' 1. / l 1/.4 AP If e ' l 4
Phone # : LZZ ) � � Fax# :
"Z
Signature: a ri, Date: - 7 CL2_
(Owner or authorized agent )
Mail, fax or email the WPCSOCC , 1618 Mail Service Center, Raleigh , NC 27699- 1618 Fay : 919. 715 . 2726
original to: Em$ilLVert*dflflflC � llCdeflr.2Qv
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: ?090 US Hwy 70 225 Green St 610 E Center Ave 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax : [phone] Fayetteville 28301 -5043 MooresviUe 2S1H Fax : [phone]
Phone : [phone] Fax : [phone] Fax : [phone] Phone : [phone]
Phoen : 910.433 .3300 Phone: 704.663 . 1699
Washington Wilmington Winston-Salem
943 Washington Sq Mail 127 Cardinal Dr 450 W . Hanes Mall Rd
Washington 278S ) Wilmington 28405 -2845 Winston - Salem 27105
Fax : [phone] Fax : [phone] Fax : [phone]
Phone: 252 .946.M81 Phone: [phone] Phone: [phone]
(Retain a copy of this form for your rccords)
Revised O52OI5