710070_Operational Agreement_20190208

Feb. 8.2019 11:24AM No.3062 P. 12
Animal Waste Management System Operator Designation Form
WFCSOCC
NCA.0 15A 8F ,0201
Facility/Farm Name:
Q
r a -
Permit * AWS _,1
OO -i O
Facility ID#:
County: P l° r
Operator In Charge (OIC)
Name: er%' — D ec.,✓ef
3Yysr Middle Last Jr. S} sm.
CertType / Numbor:AW 0 0 ;�, 6 !y' 'Work Phone:
Signature. Af �' L44-- Date:
"I certify that I agree to my designation a8 the Operator in Charge for the facility noted_ I understand and will abide by the Tiles and rognlationS
pertaining to the responsibilities set forth in 15A NCAC 08F .0203 and faak9 to do so cab result in DisciplinaryAetlons by the Water
pollution Control System Operators Certification Commissions"
4
Back-up Operator In Charge (Back-up OTC) (Opttortap '
Name:
Celt Type / Dumber:
Signature,
Middle Las( -A, &, ere_
Work phone:
Date:
`I certify that Z agree to my designation as Backup Operator in Charge for the faoility uotel I understand and will abide by the rules and
regulations pertaining to the responsibilities set forth is 15ANCAC 08F .0203 and failing to do so can result in Disciplinary Actions by the
W2W pollution Control System Operators Certification Commission."
Own.er/PermitteeName: A %e&)L 3
.Phone#:.( 910) Fax#: A
Signature: Date:
(Owner or fifithodzed6fetQ
MW4 fax or email the 'WFCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Far: 919.715.2726
original to. )Email•; cortadmin nedenr, ov
Mail or fax a copy to the Ashevdle
Fayetteville
Mooresville
appropriate Regional Office: 2090 US Hwy 70
225 Green St
610 E Center Avc
SWannauoa 28778
Suite 714
suite 301
Fax: [phone]
Fayetteville. 28301-5043
Mooresville 28115
Phone: [phone]
Vma 910.486.0707
Fax: [phone]
Moen:910.4333300
'Phone:[phone]
Washington
PVilmington
PVia®Eon-Salem
943 Washington SgMall
127 Cardinal Dr
450 W. $ants Mall lid
Washingtoa27889
Wilmington28405 2845
Winston-Salem27105
Fax:[phone]
Fay:910.350,2004
Fax:[phone]
Phone: 252,946.6481
phone; 910.796,7215
Phone: 336,770806
(Retain a copy of this form for your records)
Revised 05-2015
Raleig4
3 800 Barrett,Dr
Raleigb 27609
Fax: 919.571,4718
Phone:919,791.4200