310017_Operator Designation Form_20181220

Dec, 20, 2018 1 : 50PM No. 2605 P, 1
Animal Waste Management System Operator,Designation Form
WPCSOCC
NCAC 15A 8F.0201
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Facility/Farm Name: ���r�n� eC
Permit#: (�W 3�O rU I _ Facility M#: 3� - J 1 County: i
Operator In Charge(OIC)
Name: rezQ 3 L n-6n .7-
Prn MMdle Ltrr( A,Sr,ek.
Cert Type/Number: R W A 196 a s Work Phone:(
Signature. �'l� Date: 1.2-aD - A? -
T eert4 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 09F.0203 and failing to do so can result in Disciplinary Actions by the Water
Pollution Control System Operator&Certification Commission."
Back-up Operator In Charge(Back-up OIC) (Opidonal)
Name:
'Rrrr Middle Lan Jr,S1 etc.
Cert Type/Number: Work Phone:
Signature: Date:
"I certify that I agreo 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 1SA 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 T L
Phone# 1110 a% 5 - ) 3 5 7 Fax#: (SI0 wl iY
Signature:�� — Date: I.Z
(Owner or sut w imd nt)
Mail,fax or areal!the WPCSOCC 1618 Mail Service Center, Raleigh,NC 27699-1618 Fm 919.715.2726
original to: _.
Mail or fax a copy to the Ashevillo Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 223 Green St 610 8 Center Ave 3800 Barrett Dr
Swatmanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:[phone] Fax:910,486,0707 Fax:[phone] Phone:[phone]
Phoen:910,433.3300 Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington,Sq Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27699 Wilmington 28405-2845 Winston-Seilem 27105
Fix:252146.9215 Fax:[phone] Fax-336.776S797
Phone:[phone] phone;910.796.7215 Phone:336.77C"00
(Retain a copy of this form for your records)
Bevit dos-2o15