310246_Operational Agreement_20220706

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name: C & J Finishers
Permit#: AWS-310246 Facility ID#: 31 - 246 County: D.iplin
Operator In Charge (OIC)
Name: James Douglass
First
Middle
Blackmore
Last
Cert Type / Number: # 1007354
Signature:
Jr, Sr, etc.
Work Phone: ( 91/0)2449-2008
Date: O/Z
"I certify tha "'agree to my designationignation 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)
First Middle Last Jr, Sr, etc.
Cert Type / Number: Work Phone: (
)
Signature: 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: C & J Finishers -James Douglass Blackmore
Phone #: [phone]
Signature:
Mail or fax to:
Fax#:( 1
WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]
(Retain a copy of this form for your records)
Date: 0//Ze—
Revised 8/2007