540034_OIC Designation Form_20241106 (2)

Animal Waste Management System Operator Designation Form
WPCSOCC, 1618 Mail Service Center, Raleigh. NC 27699-1618
Facility/Farm Name: ��r nnc-� (-iytn o Fc ern 7�CT��
Permit #:1--f A S SLI M3 Facility lD#: 5�_—_ County: LPnO ; r
Operator In Charge (OIC)
Name:_"hen )IPA Monet n ld (iXrSFS; s
First Middle Last Jr Sr, etc.
Cert Type / Number. w �j DDt)'S) Ln Work Phone:
Signature: gr-_� -Y< Date:�!_D(o �p �
"I certify that I agree to my designation as the Operator in Charge for the facility noted. 1 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: Li Z0. N Kl-10 o . /� ( 51, -, i
First Middle Last Jr, Sr, eta.
Cert Type / Number: J�WCl� -i /7i CIA-I-)S 7� Work Phone:
Signattn•e �. i tr}tLC C tl[r�l 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 Certification Commission."
Owner/Permittee Name:
Phone#:�Sta,)5(nii- Jyli
Signature: 7A40j.5L Date: i 1 C)&-a CQV
(Owner or authorimd agent)
Eittall this forin to: [e-mail]
Mail or fax to your
DEQ Regional Office (a) -
email to your contact)
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phoen: 910.433.3300
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fux: 910.350.2004
Phone: [phone]
Mooresville
610 B Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Wbrston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:919.79IA200
Revised 112023
(Retain a copy of this form for your records)