310015_Operational Agreement_20190208

Feb, 8.2019 11:22AM
No, 3062 P. 4
Aiaiinal Waste Management System Operator Designation Form
WCSOCC
NCA,C'15A 8F .0201
Facility/Farm Name: � �j p G. 1, 0 V.,
Permit #: T- 2s \ Q 0 i Facility W#: - 1 S� County: i
Operator xn Charge (OIC)
Name:
S-M.91 Mddle -Lose
Cert Type / Number: RwA_) 96 a s
Tr, Sr. etc.
Work phone: (_ 5f0) 9 &--1.3 3^ 7
Signatwe • , ,� Date: A2 -o20 --
"I car* 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 rosponsibttlities set forth in 15ANCAC 08F.0203 and failingto'do so canresultin.Diseiplinmy Actions by the Water
Pollution Control System Operator8 Certification Commission_"
Back-up Operator In Charge (Back-up OIC) (Optional)
Name:
fiat Middle Last Jr. Sr, etc.
Cert Type / Number: Work phone:
Signature. Date:
"Icertify 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/Permittee Name: r ex— T L;,i 4-d ri
phone #: (1 lo) a2 S -13 5_1 Fax#:
Signature: Date:_
(Oanerorauthorized ent)
Mail, fax or emait the WPCSOCC 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: 919.715,2726
original to: IBM t o.'
Mail or fax a copy to the Asheville
P'ayctteville
Mooresville
appropriate Regional Qj ice, 2090 US Hwy 70
225 Green St
610 E Center Ave
Swannanoa 28778
Suite 714
Suite 301
Fax: [phone]
Fayetteville 28301-5043
Mooresville 2g115
Phone:928.296,4500
Fax:910,486.0707
Fax:[phone]
Phoen: 910.433.3300
phone; 704.663.1699
Washington
Wilmington
Winston-Salem
943 Washington SgMall
127 Cardinal Dr
450'W. Hanes Mall lid
Washington 27899
Wilmington 28405-2945
Winston-Salem 27105
IF= 252,946.9215
Fax: 910.350,2004
Fax: 336.776,9797
Phone:[phone]
Phone:910.796,7215
Phone:[phone]
(Retain a copy of thisfornifor your records)
ts.evisod os 2015
Raleigh
3 800 Barrett bx
Raleigh 27609
Fax: 919,571.4718
Phnne:919.791.4200