310015_OIC Designation Form_20231012

Animal Waste Management System Operator Designation Form
Facility/Farm Name:
Permit #: 6 0 81
Operator In Charge (OIC)
Name:
RVIrrin
WPCSOCC
NCAC 15A 8F .0201
Facility ID#:_- County: `L)(jrj
Jr, Sr, etc.
Cert Type / Number: Work Phone: (q/`/) ) 1-9 V' 11�
Signature.—&'Wu�y� �Gt!tN� Date: 1011V2,3
"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 Last Jr, sr, etc.
Cert Type / Number:
Work Phone:
Signature: 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: 1 to /d"/t511/f U
Phone #: AO ) 11s_S — /605' Fax#: ( )
50,
50,
50,
50, PA
Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Email- eertadminamedeni•.soe
Mail or fax a copy to the
Asheville
Fayetteville
Mooresville
appropriate Regional Office:
2090 US Hwy 70
225 Green St
610 E Center Ave
Swannanoa 28778
Suite 714
Suite 301
Fax: [phone]
Fayetteville 28301-5043
Mooresville 28115
Phone:[phone]
Fax:[phone]
Fax:[phone]
Phoen:910.433.3300
Phone:[phone]
Washington
Wilmington
Winston-Salem
943 Washington Sit Mall
127 Cardinal Dr
450 W. Hanes Mall Rd
Washington27889
Wilmington28405-2845
Winston-Salem27105
Fax:[phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
(Retain a copy of this form for your records)
Revised 05-20 t5
Raleigh
3800 Barrett Or
Raleigh 27609
Fax: [phone]
Phone:[phone]