820485_OIC Designation Form_20190501

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Faciiity/Farm Name:..tg,`�' dd t"'o-st"e-Z
Permit #: _ . ,_ Facility ID#: County:
Operator In Charge (OIC)
Name -
First Mtddle Last Jr; sr, etc.
Cert Type /•Number: �qSM6,
Signature: Ltb
Work Phone: 0/0 ) r'_-Wk - f CJ:Zl
Date: _ ,!ti 9
"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 OTC) (Optional)
Name:
First Middle Last
Cert Type / Number: _ .. _ .
Signature:
Jr, Sr. etc.
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;
Phone #: 0yto) `It 2�,"' Fax#:
Signature: ' • _ d Date:
(Owner or authorized agent)
Mail, fax or email the
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to:
Im""i- It certadmin, !ncdenr:
Mail or fax a copy to flee
Asheville
FayettevMe
Mooresville
Raleigh
appropriate Regional Office:
2090 US Hwy 70
225 Green St
610 E Center Ave
3800 Barrett Dr
Swannanoa 28779
Suite 714
Suite 301
Raleigh 27609
Fax: [phone]
Fayetteville 28301-5043
Mooresville 28115
Fax: 919.571A718
Phone:828.296A500
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phoen:910.433.3300
Phone:[phone]
Washington
Wilmington
Winston-Salem
943 Washington Sq Mall
127 Cardinal Dr
450 W. Hanes Mall Rd
Washington 27889
Wilmington 28405 2845
Winston-Salem 27105
Fax:[phone]
Fax:[phone]
Fax:[phone]
Phone; 252.946.6481
Phone: [phone]
Phone: [phone]
(Retain a copy of this form for your records)
Revised 05 2015