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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 (010(TION NUMBER O(A1 DATE OF EMPLOYMENT: / ' <br /> NAME:Ske DATE OF BIRTH: <br /> P OSITION TITLE: EMAIL ADDRESS: mC1ea <br /> CURRENT AUTHORIZATION IN: "U <br /> ( t_+�c ( �.�Lfi` ( )OSW ( ..)TATTOO <br /> ( ) CLPP ( ) MH&FFH ( LS ( )WELLS <br /> (To be eligible for delegation of authority the individual must be employed by a local health department.) <br /> COUNTY OF EMPLOYMENT: Q (n HEALTH DIRECTOR: A e—r I e— &Y(er) <br /> ADDRESS: <br /> COUNTY IN WHICH CONTRACT WORK IS REQUESTED: 04pt j al <br /> ADDRESS: d0 <br /> TYPE OF AUTHORIZATION REQUESTED: <br /> ( )CCC ( FLI ( ) OSW ( ..)TATTOO <br /> ( ) CLPP ( ) MH&FFIH ( ) POOLS ( )WELLS <br /> BEGINNING DATE: © 1 UI I 1-acl,113! (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 co ractual basis. <br /> DATE: 08 /0, boll- <br /> 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 />