HomeMy WebLinkAbout540025_OIC Designation Form_20240808R ECHIVEDINCO ENWIE)WR
:animal Waste Management System Operator Designation For a 12 2024
►1'PCSOCC, 1618 NI oil Service Center, Raleigh. NC 27(iW 161R
Water Qualsy
Hegtanal Operations Section
Washinctton Regional Offr
Las�+�lCed
Facilit}�lFarin \ante; �i Dt`l��{�}!�f ��f�rY1
Permit _6w_S.3 400 a5 Facility ]D#: County:
Operator In Charge (QlC)
1 ''`r dtrddlc Lam Jr. Sr. err.
Ccl1 l vpc hiumhcr:. „i z Work PhoneK:
SY�rrafrrrt•._
"! certify thst I agrt.+e in my dexignation as the Operator in Charge for the facility noted. I undcrsland and %viII abide by the rules and regulations
penaining to the responsibilities wl funh in 15A NC'AC 09F .U243 and lailitlg to do so can result in Dmaplinary Actions by the Water
P014 lion Control Sysieni Operators Certification Commission."
Baek-up Operalor 1n Charge (Back-up 01(') (Oprinrtaf)
?flame:
Fier Middle Law Jr. Sr. err.
Cert Type 1 Number: 'Work Phone: [-
Sigmature;
fkr[e.•
" I certify that I agrcc lu my dcsigoation a> Back-up Operator in Charge rnr the facility noted. I un&msland and %wilt abide by the niles ;Ind
regulations pertaining to the rcsnvnsibililiew set forth in 1SA NCAC' 0RF ,0?03 and failing ru ciu so can resull in Disciplinary Actions by die
Water Pollution C'0n1m11W.4cm Operatur5 Cerlirtcarion Commission."
C}wncrl4'errmitt
ryec fiame:���
Path: J
rilwncroraulh.uir rfl ❑ftic:
IlnailtlrisJnrnrl°: Cerladmin�rrdcLl.nc.iGu}•
i1:Tui1 nr fore no) wtop
DEQ9 Red+inrruf off;c ' (ni�
octaly to yuirr ruulact)
Aslun ifrr
20t)(I 1:4 i lx'y ?u
Swalnranoa 2X778
Fa.t : 82h.299.7043
PhWre: 428-296,4500
Washington
943 Washinglon Sq hf:111
Washiilglnn 27NNY
Fax; 252.946.9215
Pliot e. 252,946.6491
Fayelrevllle
225 Green sl
Siiiie 714
Vaycttevillc 28301-5043
l'nt: 910-486.07117
lrhur n: 910,433,3301)
Wilmiiiglun
127 ('tnxhrml far
Wihninglim 2M405 2845
Fax: 910.350.201W
Phurle: 910.796,7215
Mooresville
Ruleigh
6111 F. ('enter Ave
38Ut1 rlat'rx-11 17r
Suite 301
Raleigh 276119
Mooresville 28115
F2x:919.571.4719
Fn rc: 704.663.6040
1'honc:919.791.41110
Phone: 7114.663.1691)
Win%ion-Salem
4% 11. I lanes Mull Rd
Will oil-Salcln 27105
11"ItU 336.776,9791
Phnnc: 336,776.99111)
r16wiiu a I-opy nJ'tlus lor►lr 1w. r urrr records)
kerrx'd 1112073