820265_OIC Change_20220324

Facility/Farm Name:
Permit ii: l]-!FJ(" 1O'c0
Animal Waste Management System Operator (Designation Form
w/PcsOcC
NCAC 15A 8I' .0201
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Coca
Facility 11)1i:
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ttTriKeliiirgWRIO
Name: d
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Middle
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Las!
Cert Type / Nu€ aI er c Qt; t
Sigiiarure:1-9Cr';v^`r"''fl
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Work Phone: ((-;? j0
"I certify that 1 agree to my desio.nation as the Operator in Charge for the ;agility noted. I understand and will ;tl:ride by the rules anti regulations
pertaining to the responsibilities sot forth in 1511 NCAC 08F .0203 and 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:
Firs“ ,L1ietrl!.
Cert Type / Number:
Lew
Sib11111t(rc.
Ir. Sr. elk.%
Work Phone:
Date:
"I certify that I aurcc to my designation as Back-up O(lcr.uor in Charge for the facility noted. !understand and xv-il1 abide by the rules tintf
regulations pertaining to the responsibilities set forth in 15A NCAC 081:.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission.-
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Signaiure: �'r. / ; x„ 1a� 1
(01K r c:r or atulionzed agent)
Fax#: ( s
Date: ` / -?-
alai!, fax or entail the
original to:
:Hail or fax rr coley to they
appropriate Regional Office::
WPCSOCC, 1618 `,Tail Service Center.
Email: certatimin(ri)ncdenr.mrry
Asheville
2090 US Hwy 7(1
Sw:lnnalma 25775
Fax: S28.299.7043
Phone: [phone](111
'Washington
9-13 Washington Sq Mali
Washington 27889
Fax: [phone]
Phone: [phone]-I81
Fayetteville
225 Gruen St
Suite 714
Fayetteville 2801-5043
Fax: 9I t1.-186.0707
Phnrtt: 9111.433.33(10
'Wilmington
127 Cardinal 1)r
\Vilirrinclnn 28405-2845
Fax: 911).35(1.2(1(14
Phone:[phone]
Raleigh, NC 27699-1618
Fax: [phone]
lanresV ille
610 0 Center Ave
Suite 301
tvinoresvillc 281 1 j
Fax: [phone]a
Phone: [phone]
11'ittston-Salem
450 \\:'.'lanes 1Zci
Winston-Salem 27 1(15
Fax: [phone]
Phone: [phone]
(Retrrirr rr craft' aj 11!LA /item lih;•.17o1o1 rTc(rrcic)
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone](1(1
levis,:J l0-2015