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HomeMy WebLinkAboutWQ0016165_Other_20191202Water Pollution Control System Operator Designation Form WPCSOCC NCAC 15A 8G .0201 Permittee Owner/Officer Name: _ [� 51 8 n �oNC •1oG�riS'? Mailing Address: QS k>ts� clfKaer st City: -o%54tw-, State: t c Zip: mia- Email address: _� e�l.1600, t �+l1L: erl 11C • S ey Phone #: 334~ o14 b " 31?,a(P Signature: _ Date: l.21a [ 17 Facility Name: 1tKjag4dot RR4 r0r .I w (a7-P Permit #: dC o0s.SM. County:_ -Dk a Ors SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM! Facility Type/Grade (CHECK ONLY ONE): ✓Biologic Collection Physical/Chemical Surface Irrigation Land Application Operator in Responsible Charge (ORC) Print Full Name: Sfe- Cr t.,7 Crower /Email: SC Croonr ® (e t6!bf 6A r)C . _9a Certificate TyIPIAI,A,� rade / Number: (i� �% r I �`f Work Phone #: 3 3 (4- 3SrI - SO p Signature: �� Date: "I certify that I agree to my designation as th perator 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." ................................................................................................................................................. Back -Up Operator in Responsible Charge (BU ORC) Print Full Name: !�Uota 5 U-0h#46664 Email: f 4 ; 060kso-, (9 [q�„�J-biz_ne . y o d Certificate Type / Grade / Number: ! 2 W,* Work Phone #: 334- J49 - 39j2 F Signature: ], N"` Date: l-2 -•0 • I g "I certify that I agree to my designation as a 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 BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission." .................................................................................................................................................. Mail, fax or email the original to: Mail or fax a copy to the appropriate Regional Office: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: 919.715.2726 Email: certadmin(d.ncdenneov Asheville Fayetteville 2090 US Hwy 70 225 Green St Swannanoa 28778 Suite 714 Fax: 928.299.7043 Fayetteville 28301-5043 Phone:828.296.4500 Fax:910.486.0707 Phone: 910.433.3300 Washington 943 Washington Sq Mall Washington 27889 Fax: 252.946.9215 Phone: 252.946.6481 Wilmington 127 Cardinal Dr Wilmington 28405-2845 Fax: 910350.2004 Phone: 910.796.7215 Mooresville Raleigh 610 E Center Ave 3800 Barrett Dr Suite 301 Raleigh 27609 Mooresville 28115 Fax: 919.571A718 Fax:704.663.6040 Phone:919.791.4200 Phone: 704.663.1699 Winston-Salem 450 W. Hanes Mall Rd Winston-Salem 27105 Fax: 336.776.9797 Phone: 336.776.9800 Revised 05-2015