130686_OIC Designation Form_20210317

Animal Waste Management System Operator Designation Form
Facility/Farm Name: r 14% wr°
Permit #:
WPCSOCC
NCAC .15A 8F .0201
i
Facility ID#:
County:
�cx�arrc,S
Operator In Charge (QIC)
Fr � eee
Naive' Jr. Sr. ere.
First Middle Last
Cert Type 1 Number: A 0Work Phone:
(70
Signature:
Date:
"I certify that I agree to my designation as the Operator in Charge for the facility noted. 1 understand and will abide by the rules
and regulations pertaining to the responsibilities set forth in 15A NCAC 08F .0203 and €ailing to do so can result in T}iscipli>aary
Actions by the Water Pollution Control System operators Certification COMInission."
Back-up Operator In Charge (Back-up 010 (Optional)
First Middle Lai 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 un&,rstand and will abide by l
rules and regulations pertaining to the responsibilities set forth in I5A NCAC 08F .02t13 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control Systam Operators Certification Commission.-
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Owner/Permittee Name: �—
Phone #: (-?Z q) ': Fax#: (2�? L& `' 39
Signature: Date: -f -
(Owner or a rued agent)
Mail or fax to: WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]
(Retails a copy of this form for your records)