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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 1454— DATE OF EMPLOYMENT:_ <br /> NAME: DATE OF BIRTH: � �� <br /> POSITION TITLE: ej � 1(.l II UTAIL ADDRESS: 1� ao#w(z-ci Coto <br /> CURRENT AUTHORIZATION IN: <br /> ( krCCC ( ✓fFLI ( ) OSW ( .Q,,(ATTOO <br /> ( ✓�CLPP ( ) MH&FFH ( . POOLS ( )WELLS <br /> (To be eligible for delegation of authority the individual must be employed by a local�health department.) <br /> COUNTY OF EMPLOYMENT: Q <br /> QJla HEALTH DIRECTOR:S(�! (ICU (/ as , <br /> ADDRESS-Jq L'tlJ1�P ,ice )ew , (/ 7 i /V6 C q?-�a2/y <br /> - n <br /> COUNTY IN WHICH CONTRACT WORK IS REQUESTED: <br /> ADDRESSt,.Ty W- T <br /> TYPE OF AUTHORIZATION REQUESTED: <br /> ( tjCCC ( ELI ( ) OSW (..TATTOO <br /> ( Lj'CLPP ( ) MH&FFH ( -r'POOLS ( )WELLS <br /> BEGINNING DATE: (Please do not say ASAP.) <br /> STATEMENT OF APPLICANT <br /> I hereby request that I b authorized to enforce state laws and rules on a co ractual basis <br /> DATE: 15 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 />