310033_OIC Designation Form - Digester_20240910

Animal Waste Management System Operator Designation Form
W PCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Facility/Farm Name:
Permit #: APS31-0033
Operator In Charge (01C)
Facility ID#: 31-0- 033 County: d,AD1�_q
Name:
First Middle Last
Cert Type / Number:��
Signature.,
Jr, Sr, etc.
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Work Phone:
Date: 31 h
"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 La,ct .jr, sr, etc.
Cert Type / Number: Work Phone:
Signature:
Date:
" 1 certify that I agree to my designation as Back-up Operator in Charge for the facility noted. 1 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."
� 1
Owner/Permittee Name:
Phone #: (�f �) �� �� - r C Fax#: ( )
Signature: ret Date: G ^ '�
(Owner or authorized went)
Email this form to: [e-mail]
Mail or fax to your
DEO Regional Office (or
email to vote- contact)
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Favetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phoen: 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]
(Retain a copy of this 16rn7fnr your records)
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Re%iscd 11:2023