090052_Application_20230601

May 22, 2023
Farm: Ross Lewis Farm
Owner: Edward R. Lewis
Farm: 9-52
To whom it may concern:
I have not had hogs on my farm starting May 19, 2023. 1 am requesting a zero -hog permit. My
phone number is 910-876-2650 and my address is PO Box 264 Bladenboro, NC 28320 if you
need to contact me for more information.
Sincerely,
Edward Ross Lewis
I.-

RECEIVED
Animal Waste Management System Operator Designation Form
WPCSOCC MAY 3 0 2023
NCAC 15A 8F .0201
NC DEQ/DWR
Central Office
Facility/Farm Name: a L F_w l-3 FAR m
Permit #: f� IJ S U' 0 a S 2- Facility ID#: 0 1 -5 Z County: 1 Lei D fir✓ _
Operator In Charge (OIC)
Name: 6 w A k 0 ,doss LEu✓i.S Sr.
First Middle Last Jr, Sr, etc.
Cert Type / Number:)414/- 9 5 Work Phone: (9t^ )_ Y 7 6- z C s d
Signature: �J-�� - Date.
"I certify that I agree to my designation 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)
Name: - Ti= u EL) (LAA
First Middle Last
Jr, Sr, etc.
Cert Type / Number: A k/ - 9 2 -S S Work Phone: ( 1 l ° 1 7 *7 0 o 5- 3
J
Signature: Date: 'S 2 'j /7-3
'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:
Phone #: i q!b i Fax#: i
Signature: 4-
(Owner or authorized agent)
Mail, fax or email the
original to:
Mail or fax a copy to the
appropriate Regional Office
Date: I Z-5 Z
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
Email: certadminiu:nedennLwov
Asheville
2090 US Hwy 70
Swannanoa 29779
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fag: 252.946.9215
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 29301-5043
Fax: [phone]
Phoen: 910.433.3300
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 05-2015
(Retain a copy of this form for your records)