670053_Operational Agreement_20190306

Mar 06 19, 04:41 p - p.1
Animal Waste Management System Operator Designation Form
WPCSOCC
VCAC 15A 8F .0201
Facility/Farm Name: L:4,ye -1k Hv�,Kf L `/
Permit#: &7 47 DU. 53 Facility TD#: County: �� _ D�✓
Operator In Charge (OIC)
n•
]Name: i n.ce", � � 1' �� Z 5r" i
Firer Atiddie Last Jr, Sr, arc.
Cert Type / Dumber: l r 10 a70 Work Phone: (_6l l ,
Signature: Dafe:
"1 certify That I agree to my designation as the O01—ator in Charge for the facility noted. I understand and wi:l abide by the rules and regOadons
pertaining to the responsibilities set forth in 15A NCAC 08F .0203 and foiling 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) (Optioleal)
Name:
Firer A•iiddie Last Jr. Sr, ere.
Cert Type / Number: Work Phone: (,
Signature: Date:
1certify that 1 agree to my designation as Back-up-Operaior in Charge for the facility noled. 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: �5 l�(� 6y ,,r �. ff�,� (t �•(
Phone #: �_ q i � 1 � - /31L Y 3
Signature: _5 Date:
(Owner or authorized ag
hfuU, fax or entail the
WPCSOCC, 1618 '.Flail Service Center, Raleigh, NC 27699-1618 Fax: 9I9.715.2726
original to:
Email: certadminna ncdenr.eov
Mail orfax a copy to the
Asheville
Fayetteville
Moores•111c
Raleigh
appropriate Regional Office:
2090 US Hwy 70
225 Green St
610 B Center Ave
3800 Barren Dr
Swannanoa 28778
Suilc 714
Suite 301
Raleigh 27609
Fax: [phone]
Fayeneville 28301-5043
Mooresville 28115
Fax: [phone]
Phone: [phone]
Fax: [phone]
Fax! 704.663.6040
Phone:[phone]
Phoen:930.433.3300 •
Phone.,704.663.1699
Washington
Wilmington
Winston-Salem
943 Washington Sq Mall
127 Cardinal Dr
450 W. Hanes Mall Rd
Washington 21889
Wilmington 28405-2845
Winston-Salem 27105
Fax: [phone]
Fax: [phone]
Fax- 336.776.9797
Phone:[phone]
Phone:[phone]
Phone:[phone]
(Rmsirr a cop)• of'Wa form for Four- rccor'ds
Revised 05-2015