040035_OIC Designation Form_20240916

knintal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .02111
Facilitv/Farm Name: I l E
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LLC
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Facility ID#: `f -
County: Iq tiS a I-J
Operator In Charge (OIC)
Name: Jos)AQA L f 012Sf"C_
First Middle Last Jr, Sr, etc
Ccrt Type / Number: f q 2 06 .3 Work Phone: (7U 1-1 J 7 Y -
.Signature: :�57. Date: 9 _ / 6
"1 certif 1 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 l fiddle Last Jr, Sr, etc
Ccrt Type / Number: Work Phone:
Signature: Date:
"l 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 I5A NCAC 08F .0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name: G_) H (T6 GQGCIC FA(ICMS,
Phone #: ( 70 q) 2 2) - 1-7 OS 1`ax4: (
Signature: �-
authorized agent)
)
Dole, —
Afail, fax or email the
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-161S Fax: [phone]
original to.
Email: certadminnnedenn2ov
Mail or fax a copy to the
Asheville
Fayetteville
Mooresville Raleigh
appropriate Regional Offrce:
2090 [IS Hwy 70
225 Green St
610 E Center Ave 3800 Barrett Dr
Swannanoa 28778
Suite 714
Suite 301 Raleigh 27609
Fax: [phone]
Fayetteville 28301.5043
Mooresville 28115 Fax: [phone]
Phone:[phone]
Fax:[phone]
Fax:[phone] Phone.[phone]
Phoen: 910.433.3300
Phone; 704.663,1699
Washington
Wilmington
Winston-Salem
943 Washington Sy Mall
127 Cardinal Dr
450 W. I lanes Mall Rd
Washington 27889
Wilmington 28405-2845
Winston-Salem 27105
Fax:[phone]
Fax:[phone]
Fax:[phone]
Phone:252,946.6481
Phone.[phone]
Phone:[phone]
tRetain a copy of this form for your records)
Rc% hed 05-2015