310014_Operator Designation Form_20181220

Dec, 20. 2018 1 : 5OPM No. 2605 P. 3
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A,8F.0201
Facility/Form Name: we.
Permit#: W 5 Od Facility TD#,. �_- _County:
Operator In Charge(OIC)
Name:-j4 j fr P.J0- S r1 ►�
Flra MIda17e Lash A.b;ere.
Cert Type/N'umber:_R W A 186 3 s Work Phone, ( aZ -l 3 3^7
Signature.- Date:-a2- 0 -
"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 eat fortb in 15AN•CAC 081;.0203 and failing to do ao can result in Disoiplinary Actions by the Water
Pollution Control System Operators Certification Commission.`'
Back-up Operator In Charge(Back-up OIC) (Optional)
Name:
F&.se Middle Last Jr,SY etc.
Cert Type/Number: Work Phone:
Signattme: Date:
'7 certify that I agree to my designation as l3ack-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 15ANCAC 08F.0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control System Operators Certification Commission!'
Owner/Permittee Name: 04) r ez I L jt Yi D
Phone,#: ( Slo 1 185- 13 5-2 Fax#:(510 1 AK— 1�1
Signature:4 6Z� — Date: �,2-�O —l�
(Owner or authorized (ent)
Mail,fax or email the WRCSOCC 1618 Mail Service Center, Raleigh,NC 27699-1618 Fats;919.715.2726
original to: on. Immm.
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office; 2090 US Hwy 70 225 Green St 610 2 Center Ave 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax-828.299,7043 payetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:828,296.4500 Fax:910,486.0707 Fax:704,663.6040 Phone:[phone]
Phoeb:910.433.3300 Phone:[phone]
Washington :Wilmington• Winston-Sale►u
943 Washington Sq Mall 127 Cardinal)Dr 450 W.Banos Mall Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone;252.946.6481 Phone:[phone] Phone:[phone]
(Retain a copy of this form for your records)
Uvked 05-2015