310761_OIC Designation Form_20240802

Animal Waste Management System Operator Designation Form AUG 0 2 2024
PCSOCC
NC.t(ISA8F.0201
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Faeility[Farm Name:
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Permit #: Facility ID#: 3�--1 County: i11�� it
OperatorInCharge (OIC)
Name: _J uL 1 �l:t'�i`� S e Fit 1\__--
Airsl
Cert Type / Number: 1 ` ! V (7p( --- _ Work Phone: ( ef !J 1 Q Z Li - (c 1 "7 %
Date: _ 1 7 V
'I ccm fy that 1 in f6e to my designation a the Operator in Charge fo the facility toted. I understand and will abide by the rules and regulations
r evainmg to the mponsibildies set forth in 15A NCAC 08F .0203 a id failing to do so can result in Disciplinary Actions by the Water
Pollution Control System Operator, Ccnificatxm Commissun."
Back-up Operator In Charge (Back-up OiC) (Optima!/
Name:
F ustuF --'-
C ert Type / Number..
Signature:_ -
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Work Phone:
Date
"I certify that I agree to my designation as Rack -up Operator in ('liar tc for the facility noted. 1 understand and will abide by the rules and
regulations pertaining to the resprnsihilitics set firth in 15.A NC.4C r %I' 0203 and failing to do st/ can result in Disciplinary Actions by the
Wamr Pollution Control System Operniors Cer i icafion Coomnvs,:n; "
Owner/Permittee Name:, ` Qv 15
Phone #: ( (P ) I^�QC7—�.5 _ _ ..-- Faxik_---
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Date
Mail,jax or email the W'P('SO(Y-. 1618 Mail Set ice Center. Naleigh. NC 27699-1618 Fat: 919.715.2726
original in: Email: cerladmin,A:nedenr.t ltv
.Mail urjar a copy to the Asheville
Fa• ererille
appropriate Regional (Jjftrer 2090 US Ihvy 70
22: Green St
Swannaram 2877R
Seri e 714
Fax: [phone]
F::•etwvilte 28301-5043
Phone: 8281%.45011
Fa :910.486.0707
Ph. en: 910.433.3300
wiviki"Rum
5V min,f.o,
943 Washington Sq Mall
12' ('ardmal Dr
Washington 77889
W'i n:mn tLnw 28405-1845
Fax: 252A46.9215
Fa•: 910-350.2004
Phone: [phone]
Ph. ne:910.7967215
Mooresville
Raleigh
610 E Centcr .4vc
3800 Barren Dr
Suite 301
Raleigh 27609
Mooresville 28115
Fax: [phone]
Fax: [phone]
Phnne:919.791.4200
Phone: [phone]
winstnn-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fast 336.776.9791
Phone: [phone]
(Retain a capv ,,, thiv (ono jar vow )ecords)
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