310612_OIC Designation Form_20120928

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name: Christopher Boone/Boone Family Farms
Permit #: AWS310612 Facility ID#: 31 _612 County: Duplin
Operator In Charge (OIC)
Name: Stephen D. Boone
First Middle Last Jr, Sr, etc.
Cert Type / Nu ber: AWA 27198 Work Phone: (910 ) 289-2360
Signature: 1 Date: 9-28-2012
"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)
First Middle last ASr, 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: Christopher Boone
Phone #: [phone] Fax#:a '
( )
Signature: f JUILC. Date:9'28-2012
(Owner or uud' 'ud agent)
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 W007