820187_OIC Designation Form_20240814

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Animal Waste Management System Operator Designation Form
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Facitity/Farm Name: K, IIYA/u11,4
Permit #: At/ S V) d /Y 7 Facility ID#. r2 - li- 7 County: 5.,e.r 6�
Operator In Charge (OIC)
Name: l' C k/. -n qt LPG
First Middle Last Jr, Sr, ert.
Cert Type / Number: &A ./d l r01w Work Phone: (�/O 1 3f-r - d t%.;Z e �I
Signature:Date:
"1 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 firth 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 Middli Last
Cert Type / NumbeF:_ _ J�?/r!{^i /G/ ��
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En
Work Phone:
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"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 bythe
Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name: &,/ W4rr 1 Gk �SF4 �C
Phone #: ( q10) 337-31 U 1 Fax#:
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Email this form to:
[e-mail]
Asheville Fayetteville
Mail or far to your 2090 US Hwy 70 225 Green St
DEORegionalOffrce(or- Swammnoa28779 Suite714
email to your contact) Fax: [phone] Fayetteville 28301-5043
Phone: [phone] Fax: [phone]
Phoen: 910.43333M
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Date. -
Mooresville
610 B Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Sakm27105
Fax:[phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:919.791A200