310685_OIC Designation Form_20240319

Animal Waste Management System Operator Designation Form
Facility/Farm Name:
Permit #: AWS310685
WPCSOCC
NCAC 15A 8F .0201
Ann Herring Farm
Facility ID#: 31 _ 685 County:
Operator In Charge (OIC)
Name.21rd ��11 � el S. Avg
First I Middle Lust
It-, Sr, etc.
Duplin
Cert Type / Number: AW % 100 3 6 q Work Phone: (z ��) 9'-4 0 •-.3 ` 0 Y
Signature /: � - Date: •
"I certify that I agree to my designation as the Operfor 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:
Ann Herring
Phone #: 0 - Fax#: ( )
Sig natur&A Date:
caner or autho tzed agenif
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