310173_Operational Agreement_20190208

Feb. 8. 2019 11:24AM No, 3062 P. 14
Animal Waste Management system Operator Designation Form
WPCSOCC
NCAC 15A 8F ,0201
Paeility/Farm Name: (Y\ V i
Permit Facility Id#: 1 -
_� County; , pv-\_...
Operator In Charge (OZC)
Name: f 0 1�_ Co. r 4 2 r
1lYsl Jfiddle lost Jr, Sr. ere
Cert Type / Number: lit/
Signature:
Work -Phone:
Date,
,I cer4 yl 19I agree to my designation as the Operator in Charge for the facility noted I understand and will abide by the rules and rogulations
Pff[Ah )19 to the respobat'bilitics set forth is 15ANCAC 08F .0203 and failing to do so cab result in Disoiplinary Actions by the Water
Pollution Control System Operators Certification Commission: -
Back -up Operator N Charge (Back-up OYC) (Optional)
Name:
First Middle .Zest A SY, etc.
Cert Type / Dumber:
Signature
Work Phone: ( �
Dante:
I certify that 1 agree to my designation as Back-up Operator in Cbarge for the facility noted. l understand and wW abide by the rules and
regulations pertaining to tho responsibilities set forth in 15ANCAC 08F .0203 and failing to do so can result in Disciplinary Ac tions by the
Water pollution Control System Operators Certification Commission."
OwnerfPermittee Name;
Phone #: (� ��
5^' 3'S�
FaX#
Signature:
Date:_
(Owoer or ax6tdzod
aAt)
Mai% fax or email the
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to,
Email: cortadmiARnedenr.eoy
Mail orfax a copy to the
Asheville
Fayetteville
Mooresville
1Zaleigh
approp►laite Regional Office: 2090 US Hwy 70
225 preen St
610 B Center Ave
3 800 Barrett Dr
Swannanoa 28778
Suite 714
Suite 301
ltalelgb 27609
Fax: [phone]
Fayetteville 29301-5043
Mooresville 28115
Fax: [phone]E
Phone:828196,4500
1tax:910.486.0707
F'ax:704.663.6040
Pbone:919,791.4200
11hoeti:910.433.3300
Phone:[phone]
Washington
Wamingtou
'Winston-Salem
943 'W'ashington Sg Mall
127 Cardinal Dr
450'W'.11ancs Mall Rd
WasbhWon27889
Wilmington28405-2845
Winston-Salem271o5
Fax:252,946,9215
Fax:[phone]
Fax:336,776.9M
Phone:[phone]
Photae:910.796,7215
Phone:[phone]
(RgaN a copy of this fonn for your records)
Revised OS 2015