310399_Operational Agreement_20190208

Feb, 8. 2019 11:23AM No, 3062 P. 7
Animal, Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Faeility/Farm ,Name: �.,yy\ 0�
Permit #:w 5310 3 CI Facility TD#:_- County:
Operator In Charge (OIC)
Name:
xYrre 1Niddle Lost Jr, SY, ere.
CertType / Number. AWA Work Phone: (.Z S9-) S o26 — / 1—1 y6
Signature, Date:
"I certify that I agree to my designation as the Operator in Charge for the facility noted. I understand and will abide by the piles 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 Certifieation Commission_"
Back-up Ope>ator In Charge (Back-up OTC) (O,pdouaq
Name:
rust Middle Zasl Jr, SS; etc
Cert Type / Number: Work Phone:
SXgnature: Date:
`7 certify that l agree to my designation as lia&-up Operator in Charge for the facility noted. I understand and will abide by the roles and
regulations pertaining to the reap onsibilities set forth in 15A NCAC 00.0203 and failing to do so can result is Disciplinary Aotiona by the
'Water P011ution Control System Operators Cerrification Commission.,'
Owner/Permittee Name: �' p
Phone , r qin ) a 8S- 13 S- 7
(Owner oguthoti? agent)
Data: / — � - l � -
Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: 919,719.2726
original to; mail: certadfmirt nedenn ov
Mail or fax a copy to the Asheville
Fayetteville
Mooresv0le .
appropriate Regional Offlee: 2090 US Hwy 70
225 Green St
610 R Center Aac
Swannanoa 28778
Suite 714
Suite 301
Fax:[phone]
Fayetteville28301-5043
Mooresville28115
Phone:[phone]
Fax:[phone]
Fax:[phone]
phoen:910.433.3300
Fhohe:704.663.1699
Washington
Wilmington
Winston-Salem
943 Washington S g Mall
127 Cardinal Dr
450 W. Ranos Mall Rd
Washington 27889
Wilmington 28405 2845
Winston-Salem 27105
1F=- 252946.9219
Fax: [phone]
Fax: 336,776.9797
Phone:[phone]
Phone:[phone]
Phone:336,776,9906
(Rerain a copy of thisformfwryour records)
Revieed 05-2015
Raleigh
3800 liarrett llr
Raleigh 27609
p'ax: 919.571.4718
phon.e:919.791.4200