740039_Operator Designation Form_20160628

07/05/2018 ?;12PM FAX [phone]
FacilityIFarm Name:
SOUTHW000
NCAC 15A OF .0201
Permit #: a J — o e? c • Facility TDff: 74 - �' ` County: r i '
f0001/0002
Operator ist Charge (O1r)
Name: Ycr/2-/ k/ -
Fu;cr Middle
Cut Type 1 Number: 41_i4 11f 3
Signature:
iusf Jr. Sr. oh'.
Work Phone: (
Dare:
2U- l
"I certify That 1 agree to my designation as llnt Operator in Charge for the facility noted. i uudcrsiw]d chid will Abide: hr Ih4 hrlcs
and regulations pertaining to the t. ppnslhiliries tict forth in i5A NCAC 08Y' .01103 and railing ry do so can result iu Discipiii:lry
AcNcng by the Walcr Pollution Control System OrerstrasCertiAmnon Commission."
Back-up Operator In Charge (Back-up OIC) (Optional)
Littir
Firm
Madre
Cc rt Type i' Nurnlicr: ••-7 —7 4- 5
Signature:
Jr, sr, cir:_
Work ?hunt: (2Z) 3 V t- Z `/3 5
Dote:'
"I certify mat 1 agree to my designation a.. ilark•up Operator in Charge tar the facility miei l understand and will chick by the
reIcs and regulations pertaining to the ruspunaibililics net forth in 15A NCAC: 081, .(P.03 and failinr tv du +u cart result in
f]isciplimiry Actinnn by !ha WatcrP nt.dian Control System Operators CCrtilicntion('nmtninlon."
Owner/Perrnittee Name: f pf�r, 6C~oG.�
Flume #: ( "Pc,
Fux#: k L %� $ `"1
'c
Signature:
(t lunll:r tx AunHtr d agcntf
D ail or fax to: WPCSOCC
161X Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]
(Retain a copy of this form for your rcwurtle)
Rev.:11812C47
owe: --l�