540025_OIC Designation Form_20240812

RECEIVED/NCDENR/DWR
Animal Waste Management System Operator Designation FOt&YG 12 2024
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Water Duality
Regional Operations Section
Washington Regional Office
Facility/Farm Name:
Permit #: A w S s o as Facility ID#:. sy County: nil D /lam
Operator In Charge (OIC)
Name:
S
First I Middle Last
Jr, Sr, etc.
Cart Type / Number: AW /930 Z �c f Work Phone: ( !/1 S 2) Sol I - VO
Signature. (�/ j'/t/L� Y+ - Date:
"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)
Name:
First Middle Lost Jr, Sr, etc.
Cert Type / Number: Work Phone: ( 1
Signature: Date:
`9 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:
`if
Phone #: 62) S',V - A-47 Fax#: (
Signature: ?7 Y! d-74� /� lam/ 0 Date: O - 00 G T
(Owner or autho`3 cn i
Email this form to:
Mail or fax to your
DEQ Regional Office (or
einail to your contact)
[e-mail]
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sci Mail
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phocn: 910.433.3300
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Or
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 11/2023
(Retain a copy of this fart for your records)