740095_OIC Designation Form_20241029

le Management System Operator Designation Form
WKSOCC
NCAC 15A 8F .o211
FacilitY Farrm Name: . , P il/�r fad° G
Permit #: 1`�� �� 1� Facility RA `%4i County:
Operator In Charge (DIC)
Name; f f
First 11iddte Last Jr, Sr, etc.
Cert. Type 1 Number: 6V Work Phone:
Signature. y Hate;
" I certify that I agree to designation as the Operator is Charge for the facility noted, I understand and will abide by the rules
and regulations pertaining to the responsibilities set forth in 15A NCAC 118F M03 and Ceiling to do sr. can result in Disciplinary
Actions by the Water Polluiion Control System Operators Certificarion Commission."
Back-up Operator In Charge (Sack -up OIC) (Optional)
Lust Jr, Sr, et:.
Cert Type 770, _- r d Work Phone: t1 S- 17 - Vd-X 9
t
Signature: ( Date: )7, �7
"I certify that I agree to my lesignudon as Back-up Opei ator in Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities set forth in ISA NCAC 48F .D203 and iailing to do se can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission"
Owner/Permittee Name:
Phone #: f �.d� -- Fax#:
Signature: T _ I]rrte. 2
(Owner .r our d agent)
Mail or fax 11W W'PGSOcc
1613 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]