310263_Operational Agreement_20190208

Feb, 8.2019 11:23AM No.3062 P. 8
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15,A, 81+ .0201
Faeility'/Farm Name: LQ r e-g- k
Permit#: _QIWS 3IO U 63 FacuityID#: �- county: kp� i
Operator In Charge (OTC)
Name: e I e V o C--
Flirt Middle Last Jr. SY etc.
Cert Type / Number: A w A cf 91,2- (o S Work Phone: D 2 2 EL 7 3
,Date, _/ -,I " p1D19
'I certify that I agree to my designation as tbo Operator in Charge for the facility noted. I understand and will abide by the rules and regulations
pertaining to the responsibilities set forth in,15ANCAC 08P .0203 and failing to do so can result in Diaeiplinary Actions by the Water
Pollution Control. System Operators Certification Commission."
Back-up Operator In Charge (Back-up OTC) (Optional)
Name:
First Middle Lust Jr, Sr. etc. `
Cert Type / Number. Work Phone:
Mgnatut e: Date,
"I certify that I agree to my designation as Backup Operator in Cbarge for the fneility noted T understand and willabide by the rules and
regulations pertaining to the responailitics set forth in 15A WCAC 08P .0203 and failing to do so can result in bia4linary Actions by the
Water Pollution -Control System Operators Certification Commission."
Owner/Perwtfttee Name: ' 4,p eP- J U .J ph -
Phone #: ( 5 I D Pa7c#:
Si tore:
Date!
�_.
(Owne40r: agent] .
Mall, fox or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fag: 919.715.2726
original to. Email: ceqNjMhj&cdenr,goy
Mail or fax a copy to the Asheville
Fayetteville
Mooresville
appropriate Regional Of, face: 2090 US Hwy 10
225 Green St
610 B Center Ave
Swannanoa 28778
Suite 714
Suite 301
Fax: [phone]
Fayetrevillo 283015043
Mootea'villo 28115
Phone:[phone]
kax:910.496.0707
Fn:704.663.6040
Phoen:910.433.3300
Phone:[phone]"
Washington
Wilmington
'Winston-Salem
943 Washington SgMall 127 Cardinal Dr
450 W. Tunes Mall Rd
Washington 27889
Urdl[nington 28405-2845
Winston-Salem27105
Fax:[phone]
]Fax:[phone]
Fax:336.776,9797
Phone:[phone]
Phone:[phone]
Phone:336.176,9806
(Retain
a copy of this form for your records)
ztav4"ao5-2015
Raleigh
3800)3arrett Dr
Raleigh 27609
Fax: 919.57LVIS
PboneO19.791.4200