820254_OIC Designation Form_20241104 (2)

Nov U4 2U24 3:36prn
Animal Waste Management System Operator Designation Form
R'PCSOCC, 1618 Mao Service Center, Raleigh, NC 27699-1618
Facility/FarmName: lJ2�u.Cj r+ ifrlvctl
Permit #:3�1 D Z5 �J Facility ID#: -_ County: J-
Operator In Charge (OIC)
Name: 4P ki.J fflgrrrs 77rrMgn / /1
First Middle Last Jr, Sr,, elc
Cert Type / Number: r 9w 1� �s/� S� Work Phone: ( y/�) d y 3 s if
Signature: (.'Gel r Date: //— y-
"I certily that 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 OBF .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
Middle Lnvt
etc
Cert Type / Number: Work Phone:
Signature:
"I certify that I agree to my designation as Bach -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:
G
Phone q
— .2✓ S Lf
Fax#: (
)
Mail a• fax to your
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Fayetteville 28301-5043
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Washington
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Winston-Salem
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Winston-Salem 27105
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Fax, 336.776.9797
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(Retain a copy of thisformforyour records)
Reviod 1112023
3800 Barrett Dr
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Phone:919.79IA200