470011_OIC Designation Form_20240603

DocuSign Envelope ID: E14CBDB0-9AC5-4D6E-BF61-024F3lC426A2
Animal Waste Management System Operator Designation Form
Facility/Farm Name:
Permit #: AWS470011
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
CHARLES LOCKLEAR FARMS
Operator In Charge (OIC)
Facility ID#: 47 -11 County:
Name: CHARLES ANTHONY LOCKLEAR
First Middle Last
Jr, Sr, etc.
HOKE
Cert Type / N uSignellQyv9788 Work Phone:( 910 ) 217-5141
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Signature: 85Fo859FHA944o... Date: 6/3/2024
"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: CHARLES DAVID LOCKLEAR
First Middle Last Jr, Sr, etc.
Cert Type / Number: 990010 Work Phone: ( 910 ) 280-4142
Signature:
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: CHARLES DAVID LOCKLEAR
Phone #: ( 910) 280-4142 Fax#:
,e—DocuSigned by:
agent)
Email this form to.
Mail or fax to your
DEQ Regional Office (or
email to your contact)
[e-mail]
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phoen: 910.433.3300
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Date: 6/3/2024
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 11/2023
(Retain a copy of this form for your records)