310011_Operational Agreement_20190208

Feb. 8.2019 11:24AM No.3062 P. 13
Animal Waste Management System, Operator Designation Form
WP'CSOCC
NCAC 15A 8F .0201
Faeiiity/Farm Name: C-O Plbe'_ '�t 1 — "1
pemut #:WS O 0 i;acility ID#: �_- 11_ County: �� ► Y�
Operator In Charge (OIC)
Name: errs & GarLe, r
F17st Middle Last Ar, S, etc. `
Cert Tie Work.Phone: ( 9/0- .3_20 ' 74
Signature: Date:y( r
'7 certify that I agree to my designation as the Operator in Chargo for the facility noted. I understand and will abide by the rules and regulations
pertaining to the responsibilities set forth in 1 SANCAC 08F .0203 and failing to do so can result in Disciplinary Acdow by the Water
Pollution Control System Operators Certification Commission."
Back-up Operator In Charge (Back-up OIC) (Optional)
Name:
Fftr Mddle Last h., S); efC'
Cert Type / Number:
Work Phone- ( 1
Signature., Dare:
"I ccrtiiy that I agrco to my designation a813ack lip Operator in Charge for the facility noted. ,I understand and will abide by the roles and
regulations pertaining to the responsibilities set forth in 15A NCAC 00,0203 and failing to do so can result in Disciplinary Actiow by the
WstcrPollution Control System Operaton Certification Commission."
Owner/Permittee Name:
phone #: ( 10)a�5 ' 13S
(owner ar
Pax#: 16 a D ' ro
Date:, 02 �-
Many fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fag: 919,71522726
original to: Email: certadmin0nedenrx0v
Mail or fax a copy to the Asheville
Fayetteville
Mooresville
appropriate Regional Office. 2090 TJS Rwy 70
22S Greta. St
610 P Center Ave
Swannanoa28778
Suite714
Suite301
Fat: 828199.1043
Fayetteville 28301-5043
Mooresville 28115
-Phone.- 828.296.4S00
Fax: [phone]
Fam 704.663.6040
Phoen:91,0.433.3300
Phone:104,663,1699
Washington
Wilmington
Winston-Salem
943 Washington SgM4
127 Cardinal Dr
450 W. Hants Mall IZd
Washington27889
Wilmin&n.28405 2845
Winstob-SDiem 27105
Far: 252946.9215
Fax: 910,350.2004
)Fax! 336.7769797
Phone: 252,946.6481
Phone; 910.796.7215
Phone: 336.776,9806
(Retain a copy of this form for your records)
Revised 05-2015
Raleigh
3 800 E atrott Dr
Raleigh27609
Fax: [phone]
Phow-.919.791.4200