960002_OIC Designation Form_20240913 (2)

Animal Waste Management System Operator Designation Form
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-t618
Facility/Farn1 Name:
Permit#: vt � o_L FacilityID#: County:
Operator In Charge (OIC)
A9iddle ' . Last
.It, Sr, ea:.
Cent Type / Number: AR Work Phone:
SignatureDate:---I-(--
"I certify that I agree to my designation as the Operator in Charge for the facility noted. t 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:
Most
Cert Type /
Lnct Jr. S'r. etc.
Work Phone:
"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 fit Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission"
Owner/Permittee Name: elk 1't. m 11-6
Phone #:
%ntait this form to:
Mail or fax ro your
DDQ Regional Office (or
email to your contact)
[e-mail]
Asheville
2090 US Hwy 70
Swatmanon 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Wasbingto127889
Fax: [phone]
Phone: [phone]
Fax#:
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Pimen: 910.433.3300
Wilnngton
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Date:
Mooresville.
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. flancs Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: 919,571.4718
I'honc:919.791.4200
Revised 11/2023
(Retain a copy of this forin fir your records)