310016_Operator Designation Form_20181220

Dec, 20. 2018 1 :.50PM No, 2605 P. 2
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F.0201
Facility/Farm Name: See- . k 'i 4e- k 4 Sec- 64 5.
Permit#: Avis 3 A 0 c kc. Facility Ate: —County: �n 1�
Operator In Charge(OIC)
Name:d lLr4 S L ; n 4o vx
prsi M4ddle Last Jr,S) etc.
Cert Type/Number: 'A w A l U o1 S— Work Phone: (
Signature:- y Date:_ 1;-,20 -/oo
"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 15ANCAC O81'.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) (Optionao
Name:
First Mfddls Last Jr,sr,etc.
Cert Type/Number: Work.Phone,( 1
Signature: Date:
`7 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/Permirtee Name: r e,_0 L i el n
Phone#: (910 ) PL L 13 5 -7 Fax#:.(5��
signature.. Crl/ice Date:
(Owner aor uthorired Kent)
Mail,fax or email the WPCSOCC1618 Mail S"ce Center, Raleigh,NC 27699-1611 Fox;919.715.2126
original to:
Matl.o►fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate.Regional Office: 2090 US Hv/y 70 225 Green St 610 E Center Ave 3800 Barretrbr
Swannanoa,28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:919.571.471S
Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone]
Phoen:910.433.3300 Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 450 W.Haws Mall Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
Fax:252S46,9215 Fox:910,350.2004 Fax-336.776.9797
Phone:[phone] Phone-910.796.7115 Phone:[phone]
(Retain a copy of this form for your records)
Revised 05-2015