NC0084387_Other Agency Documents_20191017

tN FVDWR,
CHARLOTTE
� , POP
MO RE:;VIL F REGIONAL 0Fj::'G
E� WIViPTER
To: NC DEQ Mooresville Office- Water Quality 704-663-
• 4
Time: 1345 Hrs.
D . .. - • ! •
f
• •- Ar` r gig
1�4 Is
ou for assistance.

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM_1fWjy /DW
NCAC 15A 8G .0201 0 C'i
Press TAB to enter information W a o x
Permittee Owner/Officer Name: Jacqueline A. Jarrell MOORESVILLE FIECIONAl_ OFF!
Email Address: [e-mail]
Permittee Signature:��4" ,l /—
Facility Name: Lee S. Dukes Water Treatment Plant
Date: < �`
Permit # NCO084387
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: PC
Facility Grade: I
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: David Michael Banick Work Phone: [phone] X 260
Certificate Type: PC Certificate Grade:
Email Address: [e-mail]
Signature
Certificate #: 991159
.___J . -C_� il't .� Effective Date:
r' fq-i9
"I certify that I agree to my designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: George Greg Strother Work Phone: [phone]
Certificate Type: PC
Certificate Grade
Email Address: [e-mail]
Certificate #: 1007517
Signature: Effective Date: 1 r� /
"I certify that I agree to my designation as a Back-up/operator in Responsible Charge for the facility noted. / understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
ORIGINAL to: Email: [e-mail] Fax: [phone]
Mail or Fax a COPY to: Asheville Fayetteville
2090 US Hwy 70 225 Green St., Suite 714
Swannanoa, NC 28778 Fayetteville, NC 28301-5043
Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone]
Mooresville Raleigh
610 E. Center Ave., Suite 301 3800 Barrett Dr.
Mooresville, NC 28115 Raleigh, NC 27609
Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq. Mall 127 Cardinal Dr. 45 W. Hanes Mill Rd.
Washington, NC 27889 Wilmington, NC 2840S-2845 Winston-Salem, NC 27105
Fax: [phone] Fax: [phone] Fax: [phone] Phone:
Phone: [phone] Phone: [phone] Revised 5/2019

Facility Name: Lee S. Dukes Water Treatment Plant Permit #: NCO084387
BACKUP ORC
Print Full Name: William James Walker Work Phone: [phone]
Certificate Type: PC Certificate Grade: I
Email Address: wjwal ker@ci. charlotte. ncl. us
Signature:
Certificate #:1008566
Effective Date: 9/2"// 1
Page 2
"I certify that l agree to my designatioIr n as'al Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Milan Joseph Wanless Work Phone: [phone]
Certificate Type: PC
Certificate Grade: I
Email Address: [e-mail]
Signature:
Certificate #:1007514
Effective Dater * • 9 • / 9
"/ certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. / understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Certificate Grade: Select Certificate #:
Signature: Effective Date:
"I certify that/ agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. l understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Print Full Name:
Certificate Type: Select
Email Address:
Signature:
BACKUP ORC
Certificate Grade: Select
Work Phone:
Certificate #:
Effective Date:
"/ certify that I agree to my designation as a Back-up Operator in Responsible Charge far the facility noted. / understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 512019