310241_Operational Agreement_20220401

Animal Waste Management System Operator Designation Form
wPCSocc
NCAC 15A 8F .0201
FacilityfEarm Name: Fountain Farms, LLC / Fountain Farms
Permit #: AWS310241 Facility ID#: 31 - 241 County: Dublin
Operator In Charge (OIC)
Name: Chris E.
Fountain
First
Middle
Cert Type / Number: 7/t\jA 199�5
Signature:
Jr, Sr. etc. g //--ww �
Work Phone: (9//) 57b /Z3 72
Date:
"I certify that I agree to mdesignation 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 15A 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)
Beth S Fountain
First Middlr last
Cert Type / Number: AWA 19954 Work Phone: ( )
ttk
Jr, Sr. etc.
Date:
"I 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 08F .0203 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name:
Chris E. Fountain on behalf of Fountain Farms, LLC
Phone #: (910) 37. - 072
Signatur
r or authori agent)
Fax#: ( )
Date: 5a ZZ-
Mall 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