310015_Operator Designation Form_20181220

Dec, 20. 2018 1:51PM
No, 2605 P. 4
Animal Waste Management System Operator Designation Form
WPCSOCC
NCA,C 15A 8)F' .0201
Facility/Form Name: 4 �' 3 Se -410 h LA Sec,4i o v\ 'S I t,' —5
Permit #: SW 1 3 01 ]Facility ID#: �_- � S County
14
Operator In rCharge (OIC)
Name: Plird h
Fftr Mddle 'wr !r, SY tic.
Cert Type / Number: W 60� �r Work Phone: ( V0
Signature, %e� Date: 1,2 O
"I certify that 1 agree to my designation as the Operator in Charge for the facility noted. I understand and will abide by the rules and regulations
portaialM to the responsibilities set forth in 15A NCAC 08F .0203 and failing to do so can result is Disciplinary Actions by the Water
Pollution Control System Operators Certification Commission."
Back-up Operator In Charge (Back-up OIC) (Optiona9
Narne:
Fiat Middle Lean Jr. Sr. ea.
Cert Type / Number: Work Phone: ( )
Signature: Date. -
'I eert4 that 1 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 00.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission."
Owner/Permittee Name: r e- I L t' ti n D
Phone #: 5 to a8 S -13 S`2 Fax#: /0
Signature: Date, /.Z -.2 eq
(Owner or awhotized end
M4 fax or email the
WPCSOCC 1619 Nlttil Service Center, Raleigh, NC 27699-1618
Fax: 919.715,2126
original to. -
Mail or fax a copy to the
Asbeville
Fayetteville
Mooresville
Raleigh
appropriate Regional Office:
2090 US Hwy 70
225 Green St
610 H Center Ave
3800 Barrett Dr
Swannanoa 28718
Suite 114
Suite 301
Raleigh 27609
Fax: [phone]
Fayetteville 28301-5043
Mooresville 28115
Fax: [phone]
Phone:[phone]
Fax:[phone]
Far:704.663.6040
Phone:[phone]
ftoon:910.433.3300
Phone:[phone]"
Washington
Wilmington
'Winston-Salem
943 Washington Sq Mall
127 Cardinal Dr
450 W. Hanes Mall Rd
Was'hingtou 27889
Wilmington 28405-2845
Winston-Salem 27105
Fax:[phone]
Fax.[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:336,776,9800
(Retain a copy of this form for your records)
Rs ved 05.2015