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N. C. DEPARTMENT OF HEALTH AND HUMAN SERVICES <br /> ENVIRONMENTAL HEALTH SEC TION <br /> APPLICATION FOR CONTRACT WORK AUTHORIZATION <br /> REGISTRATION NUMBER L� DATE OF EMPLOYMENT: <br /> NAME:�C�LQV-�o �1 ►0-Z DATE OF BIRTH: <br /> POSITION TITLE:^IL,F H S — I YIS@�,�D�C EMAIL ADDRESS: �C!�O,Z �U,� v►� Cc�•.�•r��] nC_ �`p✓ <br /> CURRENT AUTHORIZATION IN: <br /> ( )CCC FLI M 0SW ( ..)TATTOO <br /> ( )CLPP ( )MH&FFH ( )POOLS ( ELLS <br /> (To be eligible for delegation of authority the individual must be employed by a local health,1 department.) <br /> COUNTY OF EMPLOYMENT:�C�Y►�i�Y1/� HEALTH DIRECTOR: �U i t��CV S <br /> ADDRESS: (/7 L YY�D��✓` GjT° \�V.�c IvG <br /> COUNTY IN WHICH CONTRACT WORK IS REQUESTED: osav'Se <br /> ADDRESS: <br /> TYPE OF AUTHORIZATION REQUESTED: <br /> ( )CCC (VI"FLI ( )OSW ( ..)TATTOO <br /> ( )CLPP ( )MH&FFH ( )POOLS ( )WELLS <br /> BEGINNING DATE: (Please do not say ASAP.) <br /> STATEMENT OF APPLICANT <br /> I hereby request that I be authorized to enforce state laws and rules on a contCAe4yal basis <br /> t <br /> DATE: L 3 SIGNATURE: <br /> INSTRUCTIONS <br /> Purpose:To request temporary delegation of authority to enforce state environmental health laws and rules in an emergency situation. <br /> Preparation:This form shall be completed by the authorized agent requesting contract authorization. <br /> Distribution: 1. Original to: Environmental Health Section,Office of Education&Training <br /> 1632 Mail Service Center, Raleigh, NC 27699-1632(Courier 52-01-00) <br /> 2. Copy: Local health department files <br /> Disposition:This form may be destroyed in accordance with Standard 6, Personnel Records,Records Disposition Schedule published <br /> by the North Carolina Division of Archives and History. <br /> Additional Forms:This form may be copied as needed. <br /> DPH-EHS 1056C(2/23/12)ADB <br />