310017_Operational Agreement_20190208

Feb. 8. 2019 11:22AM
No, 3062 P. 2
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A, 0.0201
FacWty/Farm Name: _ zYV
Permit #: _ \AJ l 3 i 0 O 11
Facility ID#: �_-� County: � i' v`
Operator In Charge (OIC)
Name; a �rezQ 3' L : n 40h Zy=
First Mid&s Lads Jr. Sf - ste•
Cert Type /Number: W 1 g61 S— Work Phone: ( �/r
Signature; Date: /,7r.,�D
' T certify that I agrce to my designation as the Operator in Charge for the, facility note& I understand and will abide by the rules and regulations
Pertaining to the responsibilities set forth ih 15A NCAC 08F .0203 and failing to do so can result in Disciplinary Actions by the Water
Pollution Control System Operators Certification Commission."
back-up Operator ,Xn Charge (Back -tip OIC) (O,ptlo ag
Name,
FYrsr Mtddle Last Jr, Sr, elc.
Cert Type / Number: Work Phone: ( �
Signattae: Date,
"I 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 sot forth in 15A NCAC 08F .0203 and failing to do so can result in Disciplinary Actions by the
Water Pollution Control Syatcm Operators Certification Commission."
Owner/Permittee Name: t? )1' r e T L Jt el 4-d 1l 7-9
Phone#: 910 i 5"-13 5-7 FaX#:6/-0 a�5 lv/yam
Signature: 0461ZDate: 1; -a 4 —/
(Owner or authorized Agr.nt)
Alan, fax or email the 'WPCSOCC 1618 Mail Service Center, Raleigh, NC 21699-1618 Fag: 919.715.2726
original to.
Mail or fax a copy to the Asheville
Fayetteville
Mooresville
Raleigh
appropriate ,Regional Office.. 2090 Y)S Hwy 70
225 Green St
610 R Center Ave
3800 ,Barrett Dr
Swannanoa28778
Suite 714
Suitt 301
Raleigh 27609
Fax: 828.299,7043
Fayetteville 28301-5043
Mooresville 28115
pax: 919.571.4718
Phone:828.296,4500
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phoen:910.433.3300
Phone:[phone]
Washington
'Wilmington
Winston-Salem
943 Washington Sq Mal]
127 Cardinal Dr
450 W. Hanes MallRd
W asliington 27869
Wilmington 29405-2845
Winston -Salon 27105
Fay; 2529469216
For. 910.3501004
Far: 336,776.9797
Phone:[phone]
Phone:[phone]•
Phone:336.776,9800
(Retain a copy of this form for your records)
Revised 05-2015