310014_Operational Agreement_20190208

Feb, 8.2019 11:22AM
No.3062 P. 1
Animal Waste Management System Operator Designatioa Form
WPCSOCC
NCAC 15A 8F .0201
Fac(Iity/Farm Name: � YV\ � e.c.a- t0 V 3
permit #: W.S DO 1 Facility ID#: 3� - �� County: ' )
Operator In Charge (OIC)
Name:
Rni
Lwr
Cert Type / Number: -A vv A j
A. SF, etc,
Work phone: 114
Date: /,7-o2 le
"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 15A NCA.0 08F .9203 and failing to do so can remit in DisciplinaryActions by the Water
Pollution Control System Operators Certification Commission,"
Back-up Operator In Charge (Back-up OIC) (Optional')
Name:
First Middle Lwr ✓r, SY, crc,
Cert Type / Number: Work phone:
Signature: .Date;
"I certify that I agree to my designation as Back-up Operator in Charge for the facilitynoted. 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 Operatora Certification Commission"
Owner/Permittee Name: r e L,; �d n
phone #: i to 018 5 = 13 5 Fax#: V/0
Signatuee. D
a(� 42 -a O --1
(Owner arar uthoriud ent) ate;
Mail, fax or email the WFCSOCC 1619 Mail Service Center, Raleigh, NC 27699-1618 Fall: 919.715.2126
original to., c erfr eo
Mail or fax a copy to the Asheville
Fayetteville
Mooresville
appropriate'liegional Office: 2090 US Hvry 70
225 Cveen St
610 E Center Avo
Swrannanoa28778
Suite 714
Suite 301
lay:828.299.7043
Faycmville28301-5043
Moonesville28115
phone; 828.296.4900
Fax: [phone]
Fax: 704.663,6040
)Phoen:910.433.3300
Phoue:704.663.1699
Washington
Wilmington
Winston-Salem
943''Washington SgMail
127 Cardinal Dr
450 W, Hanes Mall Rd
Washington 27889
Wilatington 29405 2845
Winston-Silem.27105
Fax: [phone]
Fait: 910.350.2004
)Fax; 336.776.9197
Phoeo:252.946.6481
Phone:[phone]
Phone:[phone]
(Retain a copy of this form for your records)
Revised 05 2015
Raleigh
3800 Barrettbr
Raleigh 27609
Fare: 919,571.4718
]Phone:[phone]