310057_Operational Agreement_20190208

Feb. 8. 2019 11: 24AM
No.3062 P. 11
Animal Waste Management System Operator Designation Form
` rCSOCC
NCAC ISA 8F ,0201
Pacility/Farm Name; -Ttl- 0 A e- (_
Permit #: AW S 3l 0 S Facility ID#: �_- County: D t- P i i y
Operator h Charge (OIC)
Name:
Flrsr f Middle
Jr. A etc.
Cert Type / Number: ICI 9 g % S o 'Work phone:
� 1
Sigljatuie: Date:
"1 certify that I agree to my designation m the 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 resuh in Disciplinary Actions by the Water
Pollution Control System Operators Cortification Commission." .
Back-up Operator In Charge (Back-up OYC) '(Optional
Name:
First Mddle Latt J►, A,, etc.
Cert Type /Number: Work Phone: (_ )
Signature:
Date:
"I ccr ify that I agree to my designation as Back-up Operator in Charge for the facility noted. 7 understand and will abide by the roles 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
Wate -Pollution Control System Operators Certification Commission."
Owner/Permittee Name: -�
phone #:.( �1 ��) o��i�� 13 Far#: /D)
Signature:- Date:_
(owner oyuthorgd agent)
Mail, fax or email the WIPCSOCC 1618 Maul Service Center, Raleigh, NC 27699-1618 Fax; 919.715.2726
original to: iG_c - n dui I
Afail arfax a copy to the Asheville -
Fayetteville
Mooresville
appropriate Regional Qjfice: 2090 US Hwy 70
225 Green St
610 E Center Ave
Swannanoa 28778
Suite 714
Suite 301
Fax: [phone]
Fayenevillo 28301-5043
Mooresville 28115
Phone:[phone]
Fax:[phone]
Fax:[phone]
Phova:910.433.3300
Phone:704,663.1699
Washington
Wilmington
Winston-Salem
943 Washington. Sq Mall
127 Cardinal Dr
450 W. Hanes Mall Rd
Washington 27889
Wilmington 29405-2845
Winston-Salem 27105
Fax:[phone]
F'ai.910.350.2004
Fax:336,776.9797
Phone:[phone]
Phone:[phone]
Phone:336,776.9800
(Retain a copy of this form for your records)
Roviaed 05-2015
Raleigh '
3800 $arrettDr
Raleigh 27609
Fab: 919.571.4718
Phone:[phone]
a