310556_OIC Designation Form_20240709

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facitity/Farm Name: k(47Faci1ity
PermitN: � W � 3 ID#. 00
- County: !WA�
Opera
Name;
Cert Type / Number: l D Wok Phone: ( f 1 `? 1^11
Signature: Date: / �7O�
-1 certify lhat 1 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 responu-bilities set forth in 15A NCAC 08F .0203 and failing to do so can resuh in Disciplinary Actions by the Water
Pollution Control System Operators Certification Commission."
Back-up Operator In Cbarge (Back-up OIC) fOprfon4
Name:
Fi.n Middle last Jr. Sr, ric.
Cert Type / Number; Work Phone:
Signature: Dat
-1 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 08P .0203 and fading to do so can result in Disciphnary Actions by the
Water Pollution Control System Operators Certiftcstion Commission."
Owner/PermitteeName: _0�00'r4l
Flogs
Phone k: 7 —
l i !
�t
Fax#: (Rl "1
za q
139 (r f 1 I
Signature:
y Date: !
(caner or a arirrd ag
Mafl,faroremail the
WPCSOCC, 1618Moll Service Center, R21eigh,NC27699.1618 Fax:[phone]
orWnal to:
Emali: certadnlin6ncdenrle
Mail orfax a copy to the
appropriate Regional Office:
Asheville
2090 US Hwy 70
Swaananoa 28778
Fayetteville
225 Green St
Suite 714
Mooresville Raleigh
610E Center Ave 38M Barrett Dr
Suite 301 Raleigh 276W
Fax: [phone]
Fayetteville 28301-5043
Mooresville 29115 Fax: 919S71A718
Phone:828296A500 Fax:910A86.0707
Fax:[phone] Pboae:919.791A200
Phoen:910A333300
Phone:[phone]
Washington Wilmington Winston-Sdem
943 Washington Sq Mall 127 Cardinal Dr 450 W. Hanes Mall Rd
Washington 27199 Wilmington 2WS-2845 Winston-Salem 27105
Fax;2529469215 Fax:[phone] Fax:[phone]
Phone.[phone] Phone:[phone] Phone:[phone]
(Retain a copy of this form jar your records)
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