620012_OIC Designation Form_20240117 (2)

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F.0201
Facility/Fa
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Permit R:
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Facility IDN: (a o� .LrC_Coaaty: OAT Drnar
Operator In
Chi
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Name:
A.
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Signature:
d%94, Date:
'7 unify that I,
w
v my dedgnmion ar the Operator In Charge for the facility noted, l understand and will abideby the rotated mgalstit
portaining to ft
mp
xurbilifica M forth in ISANCAC 08F.0203 and failing to do wran reach in Disciplinary Action by the Water
Pollution Conan
I Sr.
lat Operators Certification Commission:'
Back-up Op
trailer
In Charge (Back-up OIC) (Optional)
Name:
Fin,
Mlddfe Imd le 3F. nc.
Cat Type/ P
99jD(o r Work Phone: W3b )—y%S" _7503
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er —
Signature:
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"Iwnitythatl
gnu
mydesignalimm Dock -up Opmtarin Chmgefulhen�ilitynowd. lunderstandandwillabidabythomaxand
regultiflonsinettirdir
to the respmuibiliifea set forth In ISANCAC08F.0203 wAfailing Wdowm multin Diniplinory Aeriambytho
Wafer Pollution
Con
vi system Operators Codification Commission.'
APAC-ATLANTIC, INC.
Owner/Pen
flittictNeater
Phone#:
14 Fax#:
SYgnatnr¢..
oy Clarence O.arickey Date:
(
raurhsrimdsam0 PFIPSIDENT
Mail',thaorderalithe
WPCSOCC, 1619 Mail Service Center, Ralelgh NC27699-1618 Fax:[phone]
original to:
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Mail orfaxa
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inthe Aasavilb, Payeaeville Mocresole Raleigh
at 0f/9er: 2090 us Hwy 10 225 Dram St 610 E Cmer Ave 3800 extra, D,
Symnnanoa28778 Suite 714 Suite 301 Raleigh 27609
Fax: [phone] Faychaville 29301.5043 Momrsvi11e28115 Fsx:919571A71
P6oae: 928296A500 Fas: 910A86A707 Fax: [phone] Phon:919.791A'.
return 910,433.3301) Phone: [phone]
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Washington WOmingtaa Winston-Salem
%3 Washington S4 Mill 127 Cardinal IA 450 W. Haifa Mall Rd
Washington 27889 Wilmington 29495-2945 Wherwn-Salem27105
Fax: [phone] Fax: [phone] Fax: [phone]
Phone: 3n.%6.6481 Phone: [phone] Phonct 336.776.91100
(Retain a copy ofilarfonn forydur records)
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