250038_OIC_20230715

Animal Waste Management System Operator Designation Form
WPCSOCC NCAC 15A 8F.0201 REC -�
JUL 17
Facility/Farm Name:
Permit#: \WI 2Z�6031 Facility ID# �Coutitya-
Operator In Charge (OIC)
Name: _'�- 'f'Ry' kZWSA, JCMCS
First / Middle Last Jr, Sr, etc.
Cert Type / Number: 913%0 466o Work Phone: LX2 I24/i/-�2VSO
eels
Signature: �/ !X- Date:
I certify that 1 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)
First Middle Last Jr, Sr, etc.
Cert Type / Number: Work Phone:
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: P 1-e ✓ ecr� \ u" rS
Phone#:(,2 5z)2yu-') � o�o :LQ _-�2) ypy
Signature: y �,
(Owner n )
Mail or fax to: WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax:[phone]
(Retain a copy of this form for your records)
Date: 9 - /S• _20,�? 3
Revised 812007