770001_OIC Designation Form_20240617

F'acilitylr+arm Name:
Animal Waste M1ianagentenl System Operator Designation Form
WPCSOCC
NCAC 15A 8117.0201
i± L
Permit #: V h UJS T? Facility ILO: —7-7 U ( County:
Operator In Charge (OIC)
Name: _-jor&O rtM 141 C Ur rot I
First Middle . tart Jr, Sr. etc.
Cert Type / Number:
Work Phone:( 9 1 0 a 0 9
Dale: f 7 t� L/
"1 certify that I agree to my designation as the Operator in Charge far 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:
First Middle Last Jr, Sr, etc.
C:ert Type / Number: Work Phone:
Signature:
Dale:
"I certify that I agree to my designation as Back-up 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 09F .0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name: �Or l- r 0611 to CCl U L u
Phone #:
Mail, fax or email the
original to:
Fax#:
Date:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
Email: certadminnncdenr.eoy
Mail or fax a copy to Ike Asheville
Fayetteville
appropriate Regional Office: 2090 US Ilwy 70
225 Green St
Swannanoa 28778
Suite 714
Fax:[phone]
Fayetteville28301-5043
Phone:[phone]t1t1
Fax:[phone]
Phoen: 910.433.3300
Washington
Wilmington
943 Washington Sq Mall
127 Cardinal Dr
Washington 27889
Wilmington 28405-2845
Fax:252,946.9215
Fax:[phone]
Phone:[phone]
Phone:[phone]
Mooresville
Raleigh
610 E Center Ave
3900 Barrett Dr
Suite 301
Raleigh 27609
Mooresville 28115
Fax: [phone]
Fax:[phone]
Phone:[phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone. [phone]
(Retain a copy of this form for your records)
R %ised 0S-2015