540037_Operator Designation Form_20211021

Animal Waste Management System Operator Designation ForniiECFJVEDINCDENRIDWR
WPCSOCC
NCAC 15A SF .0201
Facility/F'arm Name: A 2 M F r ry
Permit #: A W S j OD 3-i Facility ID#: ~ - County:
Operator In Charge (OIC)
Name: tit ;-Y'•vert. �! L-ri_ )fna-Yt_� Y
Frrsf Addle fsrat
Cert Type / Number:
Signature:
p%D
OCT 2 5 202T
water o�gf
perattons Section
Lor Wtshington Aegionat Office
Jr, Sr, etc.
Work Phone: {e�J' L3ft�9�g-
Dare; /t9, 2J ., -
"1 certify that i agree to my designation as the Operator in Charge for the facility noted. 1 understand and will abide by the Hiles and regulations
pertaining to the responsibilities set forth in ISA 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:
First
Cert Type f Number:
Signature:
"1 certify that 1 agree to y designation as Back-up Operator in Charge for the faciiity noted. I understand and will abide by the rules and
regulations pertaining to the responsibilities set forth in 1 SA NCAC 08F .0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control Systent Operators Certiti ation Commission." �r
OwnerIPermittee Name: -CFA, ryLe5C e < a e
A
Middle
w PI/
dt-r11--8
Last
Jr. Sr. etc.
Work Phone: (ACA Y 51.' p r1)2
Date: AP//`4 t
Phone It: A,),-1,0d J r
Signature:.
cr or autltonxcd agent}
Matt, fax or email the
original to:
Mail or fax a copy la the
appropriate Regional Office:
Revised 05-201 5
fax#: L 1
Date: _ P/4)/A--)
WPcSOC(:, 1618Mai1 Service Center, Raleigh, NC 27649-1618
Email: certadminenedenr.gov
Asheville
2090 US 1-ltivy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Si Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: 910.486,0707
?hoer': 910.433.3300
Wilmington
127 (:arduial Dr
Wilmington 28405-2845
Fax: [phone]
Phone: 910.796,7215
Fax: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Hones 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]
Phonc:919.791.4200