740107_OIC Designation Form_20241110

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name: 6c))0% Ira -cc- , A L,1-6
Permit#: (Au)C- f I QWQQFacility ID#: _7i - )0 County:
Operator In Charge (OIC)
P; -tt
Name:
First Mr las Jr, Sr, etc.
Cert Type / Number. PrW lQ 1 i & L V Work Phone: ( S 2 -
Signature: Date:
T_Z4
"I certify 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 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)
First Middle Last Jr, Sr, etc.
Cert Type / Number:
Work Phone: ( )
Signature: 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: R\Dby �4c.�c� S
Phone #: (� �.) ? 1 `1-SZt51 Fax#: (QQ )
Signature: Q t gyp
I I t I $ �.1� Date: % - /0 - la)
(Owner or authorized agent)
Mail or fax to: WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax:[phone]
(Retain a copy of this form for your records)
Reviwd 871O11T

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Facility/Farm Name: QgWQ Oc-v-r, s L,LG
Permit #: (A 0& 11 QCVQ Facility ID#: `7� - 1 iJ County:
Operator In Charge (OIC)
P%-it
Name: 6 kaft a
First Mi Lar Jr. Sr. elc.
Cert Type/ Number: 4W A 01,1,V Work Phone: ( i 3 7 -
Signature: Date:
"I certify 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 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)
First Middle Last Jr, Sr, etc.
Cert Type / Number:
Signature:
Work Phone:
Date:
41 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: BawbV )4C s
Phone #: J a 7 ] `i - Fax#: GdSQ ) 7,5 ff fss (ram
Signature: �t t I t l L t /� Date; % Z} - -D, d 12 c�
(Owner or authorized agent)
Mail or fax to: WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax:[phone]
(Retain a copy of this form for your records)
Revised K/ W7

ccounty,
e
J�
Nc. -�
3
Las Work Phone:
1 `] DateJ l aD JL rules
d and will abide by the nary
I unders do a can u1t in Disctp
e for the facility noted.
fling
anon as the gyrator in nh5 i5ANCAC 08P .0203 an
set forth Certification Commission.
e5ponsibilitit
ies rotors
ontrol System
ope
harge (gack-uP 01C) (Op&nal)
jr, Sr. etc.
Last
Work Phone:
� pate:
noted. I understand and will abide by the
e for the facility d failing to do so can result in
opera in Chang 0203 an
esignation as Back-up � fission."
ing to the responsibilities set forth inrl to Certifi°ation Comm
Water Pollution Control System operators
pe
tee: S
gat#: asa
1 G a -e �,r Date:
;thoriz�� agert) �--
WPCSOCC
1618 Mail Service Center
"eigh, N.C. 27699-1618
Fax: [phone]
(Retain a copy of this form for your records)