310239_OIC Designation Form_20240909

Facility/Farm Name:
Animal Waste Management System Operator Designation Form
N1'PCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Melvin Bostic Form
Permit#: ADS31-0239
Operator In Charge (OIC)
Facility ID#: Z39 County: 0,.4.0 n
l Name: e/, it�� , a,.� 6aS � � �% r
First 19iddle' Last Jr. Sr. etc.
Cert Type / dumber: 4%_1 / '?/ 7 t Work Phone: (G}/0 )
Signature: � Date.
" 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
Cert Type / Number:
Signature:
(fiddle Last Jr. Sr, etc'.
Work Phone: (
Date. -
"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
re,ulations pertaining to the responsibilities set forth in 15A NCAC 08F .0203 and failing to do so can result in Disciplinary Actions by the
`,Pater Pollution Control System Operators Certification Commission."
Owner/Permittee Name: (aU ^ fi✓i'l l�rQ.+r` �e S� L J e-
Phone #: (Q'id) Z71- 4 1 O ( Fax;: ( )
Signature: �- _ Date:
(O\wier or authorized agent)
Email this form to:
Hail or fax to your
DEO Regional Office (o)-
emaii to vote• contact)
certadmin(d,deq.nc.gov
Asheville
2090 US Hwy 70
Swannanoa28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washimton 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Favetteville 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]
NVinston-Salem
450 W. Hanes :Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
(Retain a copy of this Mnn for your records/
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Rc%ised 11 202,