670030_Owner Affiliation Change_20190321

Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A SF .0201
Facility/Farm Name: teQ�� �a2n�
Permit #:
Facility ID#: �� _-y� County: r�r1S�d?.t�
Operator In Charge (OIC)
Name: � l e�1 (�k
Firs Middle Last
Cert Type / Ntunb�r: 9�9rI r7 4
Jr, Sr, etc.
Work Phone:( qtt/ ) 93SL- 'F7s(%'
"I certify that I agree to my designation as the OperatUr in Charge for the facility noted. I understand and will abide by [he rules and regulations
pertaining [o the responsibilities set forth in 15A NCAC 08F .0203 and failhtg to do so can result in Disciplinary Actions by [he Water
Pollution Control.Syatem Operators Certification Commission."
Back-up Operator In Charge (Back-up OIC) (Optional)
Name:
F;rcr
Cert Type /Number:,
Signature:
Middle Lact Jr, Sr, etc.
Work
Date:
"I certify that I agreeto 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:
Date: 3 �,�/- a6/�
Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
m•iginal to: 1;maiL• certadminna,ucdenr.gov
Mail or fax a copy to the Asheville Fayetteville Mooresville
appropriate Regional Offrce: 2090 US Hwy 70 225 Green St 610 E Center Ave
Swannaooa 2ft778 Suite 714 Suite 301
Fax:[phone] Fayctteville2ft301-5043 MooresvilLe28115
Phone:[phone] Fax:[phone] Fax:[phone]
Phacn:910.433.3300 Phone:[phone]
Washiugton Wilmington Winston -Solent
943 Washington Sq Mall 127 Caz'dinal Dr 450 W. Hanes Mall Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
Fax: [phone] Fax: [phone] Fas: 336.776.9797
Phoue:252.946.6481 Phane:910.796.7215 Phone:[phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Faz: 919.571.4718
Phmte:919.791.4200
(Retain a copy of this fm'rn for yorn• records)
Revised a5-2n IS