310070_Operational Agreement_20190208

Feb. 8.2019 11:24AM No.3062 P. 15
Animal Waste Management System Operator Designation Form
WPCSOCC
NCAC 15A 8F .0201
Fae/'lity/Farm Name:• a..
permit #; W S 0 01 O Facility lb#: county:
Operator In Charge (OIC)
Name: e Y, r, o is Cor4er
rsr Middle last
Cert Type / Number: w Work -Phone: ( 9/) S% 0 — 5- 7� i
Signature: Date: Q -`
'I certify that I agree to my designation as the Operator in Charge for the facility noted. I understand and will abide by the rules and regulations
pmtainmgto the responsibilities set fbrthin 1SANCAC 08F .0203 and failing to do so can result in Discip1bmyActions by the Water
Pollution Control System Operators Certification Commission."
Backup Operator In CBa:rge (Back-up OIC) (Optional)
Name:
rn Middle %asr Jr, Sr. cm.
Celt Type / Number; Work Phone:
SYgnatu�e: Date,
' I certify that I agiee to my designation as Back-up Opera for in Cbarge for the facility noted_ 1 understand and will abide by the Hiles and
regulations pertaining to the rcsponsibiilitics set forth in 1SANCAC 08F .0203 and failing to do so can result in Disciplinary Actions by the
WatcrPollution Control System Operators Certification Commission."
Omler/Peinuttee Name:
Phone #: ("I �) S '� 3 Fax#. LIV0.
Signature:
Date:
(Owner o(adih agent)
Mail, fax or entail the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Flax! 919.715,2726
original to: Email; certadmin nedenx. ow
Mail or fax a copy to the Asheville
Fayetteville
Mooresville
Raleigh
appropriate Regional Office: 2090 US Hwy 70
225 (teen St
610 L Center Ave
3800 Barrett Dr
Swannaaoa28778
Suite714
Suitc301
Raleigh27609
Fax: [phone]
Payettevilk U301-5043
Moorasville 28115
Faz: 919.571.4718
Phone: 928.296,4500
18axt 910.486.0707
Fax: [phone]
Phone:[phone]
Phoen.910.433-3300
Phone:[phone]
Washington
Wilmington
Winston-Salem
943 Washington Sg Mall
127 Cardinal Dr
450'W. lianas Mall Rd
Washington 27889
Wilmington 28405 2845
Winston-Salem 27105
Fax:292.946,9215
Fay:910350,2004
Fax:[phone]
Phone:252946,6481
Phone:[phone]
Phone:[phone]
(Retain a copy of this form for your records)
reined oS-2015