310770_OIC Designation Form_20240226 (2)

Animal Waste Management System Operator Designation Form
WKSOCC
NCAC 15A 8F .0201
Facility/Farm Name: ��TT�s 4e cAv Avoop"
Permit #: 44/69/0770
Operator In Charge (OIC)
Facility ID#: 77D County: El��in
Name: Marshall Scott Britt
First Middle Last Jr, Sr, etc.
Cert Type /Number: AWA 19629 Work Phone: ( 252 ) 560-9092
Signature: / "vim Date: �1 ' 1 �-�''
"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)
First Middle Last Jr, Sr, etc.
Cert Type / Number:
Signature:
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: Marshall Scott Britt
Phone #: [phone] Fax#:
w L
Signature:J&t0lo-Date:
(Owner or authorized agent)
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)
Revised 8/2007