040033_OIC Designation Form_20240916

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC I5A 8F .0201
Facility/Far/m�,N.a1me: �11t�� RaG►� ��2MS I LL C, I TI.J- �/� OAY� A�
Permit #: A �i5 � q �©3 3 Facility ID#: 33 County: 4NS D N/
Operator In Charge (OIC)
Name: JoSgUA Lf pU P..
First ,diddle Last Jr, Sr, etc
Cert Type / Number: q D 63 Work Phone: (-70q 5 B— 3 (r, ` 1 j
.Signature: I. !'��-�-� � Dale; 1 '/� — 2 7
A certi at 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 ,diddle Last Jr, Sr. etc
Ccrt Type / Number: Work Phone:
Signature:
Dale:
" E 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: .iJti} h 1 �� S ©C Egsc- r1S , L lrC_ ,
Phone#:(-7aq) 2-z — a
Signature
_,15cr or atith..wd agent)
Fax#:
Date: C� - 16 - Z '7
Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Email: certadmin(a�ncdenr.gov
Mail or fax a copy to the Asheville
Fayetteville
appropriate Regional Office: 2090 US Il%Ny 70
225 Green St
Swannanoa 28778
Suite 714
Fax:[phone]
Fayetteville28301-5043
Phone:[phone]
Fax:[phone]
Phoen: 910.433.3300
Washington
Wilmington
943 Washington Sq Mall
127 Cardinal Dr
Washington 27889
Wilmington 28405-2845
Fa x: 252.946.9215
Fax:910.350,2004
Phone:[phone]
Phone:[phone]
Mooresville
Raleigh
610 E Center Ave
3800 Barrett Dr
Suite 301
Raleigh 27609
Mooresville 28115
Fax: [phone]
Fax:704,663.6040
Phone:[phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: 336,776.9797
Phone: [phone]
(Retain a copy of this form for your records)
Rat,xd 05-2015