310763_Operational Agreement_20190208

Feb, 8, 2019 11:23AM
No, 3062 P. 5
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC•15A 81F .0201
Facility/Farm Name.
permit #: RVJS 3 103 l acility ID#: County: _ (�
Operator In Charge (OIC)
Name: %CI vlk I �a� f-Fl-AUV" G r
first
Cert Type /Number: W $�
Lost
Jr, &' em -
Work phone:
Date:i".), —I':�
"I certify that I agree to my designation as the Operator in Charge for the faoiltty noted, I understand and will abide by the rules and regulations
pertaining to the responsibilities set forth in 15A NCAC 09P .0203 and failing to do so can result in Disciplinary Actions by thc•Water
Pollution Control System Operators Certification Commission."
Back-up Operator In Charge (Back-up OIC) (OP60ftay
Name:
FYrst Middle Last Jr. A; ere.
Cert Type / Number: Work phone:
Signature:,
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 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."
Owncr/Permittee Name: i' L ►' vx A-6 m ^_
'hone #• 0 a� 5 — I5 j pax#: L�
Signature:
(Owner or aaigWie3 ag t) Date:_
Mail, fax or email the
original to,
,
Mail or fax a copy to the
appropriate.Regional Office:
WKSOCCI 3 618 Mail Service Center, Raleigh, NC 27699-1618 • Fax: [phone]
IT
. ceIrm UU c j
Asheville
2090 US Hwy 70
Swomanoa 28778
Fax: [phone]
phone: [phone]
Washington
943 Washington Sy ball
Washington 27889
Fax: [phone]
Phone: [phone]
'Fayetteville
225 Green St
Suite 714
Payetteville 28301-5043
-Vay: 910.486.0707
Phoeb: 910.433.3300
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: 910.350,2004
Phone: 910.796,7215
Moortwille
610 E Center Ave
Suite 301
Mooresville 28115
Pax: 704.663.6040
phone: [phone]
Winston-Salem
450 W. Hanes Mall 1W
Winston-Salem 27105
Fax: 336.176,9797
Phone: [phone]
Raleigh
3 800 E arrettlbr
Raleigh 27609
Fax: 919S71.4718
.Pbone:919.791.4200
Dzvlued 05-2o1s
(Retain a copy of thisfor►nfor your•recorrls)