040034_OIC Designation Form_20240916

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F A201
Facilitv/Farnnm Name: LJt� lTe K0 CV- FA P—NAS I LLC . P rz A 20 9OA-A(a9 FA2M
PrrmIO
it #; W S Q 0 3 q Facility ID#: - 3 County: A N�O
Operator In Charge (OIC)
Name: —�O S k U A L, pl) i'se—g,
First huddle Last Jr, Sr, etc
Cert Tyke / Number: 10((� - O b Work Phone: J0 4 S7 F, 3 691
Signature: � Date. p` - I & - Z
"] certifv t 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:
Middle Last Jr. Sr, etc
Work Phone:
Date:
"I certify that l agree to my designation as Sack -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 Certification Commission "
Owner/Permittee Name: W kL 1 1 6- K 0 C K F (�P�l t L L C ,
Phone #:(70q) �Z� — t1 (35
Signature:
r or authonccd agent)
Fax#:
Date: C�- l fd - 2
Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Email: certadmin(a.ricdenneov
Alail or fax a copy to the Asheville
Fayetteville
appropriate RegionalOffece: 2090 US Hwy 70
225 Green St
Suannanoa 28778
Suite 714
Fax: 828,299.7043
Fayetteville 28301-5043
Phone- 828.296.4500
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:[phone]
Phone:[phone]
Rni-d Os_2015
Mooresville
Raleigh
610 E Center Ave
3800 Sarrett Ur
Suite 301
Raleigh 27609
Mooresville 28115
Fax: [phone]IS
Fax:[phone]
Phonc:919.791.4200
Phone: [phone]
Winston-Salem
450 W. I lanes Mal I Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
(Retain a copy of this farm for your records)