090183_OIC_20230821

Animal Waste Management System Operator Designation Form RECEIVE.
WPCSOCC AUG 212023
NCAC 15A 8F .0201 ^
uEp ��� IC LLEREl09NA60FFICE
Facility/Farm Name: BLACKMON FARMS , LLC-
Permit#: AWS090183 Facility M#: 09 - 183 County: BLADEN
Operator In Charge (OIC)
Naine: AARON LAVON BLACKMON
First Middle Last Jr, Sr, etc.
CertType/Number: AW/1010369 Work Phone:( 910 ) 258-7412
AUGUST 15,2023
"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: ISAAC B. SINGLETARY
First Middle Last Jr, Sr, etc.
Cert Type / Number: AW/ 16 3 0 7
Work Phone: ( 910 ) 874-3198
Date: AUGUST 15 , 2 0 2 3
ISAAC B. SINGLETARY a
"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: AARON LAVON BLACKMON
Phone #:
Fax#:
Date: AUGUST 15,2023
(Owner or authorized agent) AARON LAVUB t31_jAU!Us1U1N
Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Ednall'l�cerfa°gmtria;�'icderstl-uoi
Mail or fax a copy to the
Asheville
Fayetteville
Mooresville
appropriate Regional Office:
2090 US Hwy 70
225 Green St
610E Center Ave
Swannanoa 28778
Suite 714
Suite 301
Fax: [phone]
Fayetteville 28301-5043
Mooresville 28115
Phone:[phone]
Fax:[phone]
Fax:[phone]
Phoen:910.433.3300
Phone:[phone] .
Washington
Wilmington
Winston-Salem
943 Washington Sq Mall
127 Cardinal Dr
450 W. Hanes Mall Rd
Washington 27889
Wilmington 28405-2845
Winston-Salem 27105
Fax: [phone]
Fax; 910.350.2004
Fax: [phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
(Retain a copy of this form for your records)
Revised 05-2015
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]