040036_OIC Designation Form_20240916

Animal Waste Management System Operator Designation Form
W PCSOCC
NCAC 15A 8F .0201
FaciligfFarm Name: w H 176 ROCK Fit if —MS L L C I W 'N 1 TE e, OLK D A le,l FAKE'
Pcrtttit #: AWC 0 4 00 3 6 Facility I1)#: 3 (C� County: A /�,lSaN
Operator In Charge (OIC)
Name:
>__ 1PQRS `EZ
First ,huddle fast Jr, Sr, etc
Ccrt Type /Number:
9'� -10 7 5 Work Phone: ( r'
Signature: __air / Date:
"I certify tha(41g-ree 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 -rip OIC) (Optional)
Name:
First
Ccrt Type / Number:
Signature:
Middle fast 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
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 Calification Commission."
OWner/Permittee Name: w (4 l I E i�0 CK Ft9 2 tA,.5 , LL C .
Phone #: (70Y, 2 z ( ^ 7 D S Fax#: p,
Signature. Date:
r nr authorized agent)
Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Email: certadminamedenneov
Alail or fax a copy to the Asheville
Fayetteville
appropriate Regional Office: 2090 US Hwy 70
225 Green St
Swannanoa 28778
Suite 714
Fax: [phone]
Fayetteville 28301-5043
Phone:[phone]
Fax: [phone]
Phoen: 910.433.3300
Washington
Wilmington
943 Washington Sq Mall
127 Cardinal Dr
Washington 27889
Wilmington 28405-2845
Fax:[phone]
Fax:[phone]
Phone.- 2.52.946.6481
Phone; 910.796.7215
Rcvued 05-2015
Mooresville
Raleigh
610 E Center Ave
3800 Barrett Dr
Suite 301
Raleigh 27609
Mooresville 28115
Fax: [phone]
Fax:[phone]
Phone:[phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
(Retain a copy of this forin for your recorciv)