NC0035041_Other Agency Documents_20200122

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name: Carolina Water Service Inc. of NC
Mailing Address: P.O.Box 240908
City: Charlotte State: NC Zip: 28224 -
E
S
Facility
Phone #: ( 704-25-7990
Hemby Acres Permit #: NCO035041
SUBMIT A SEPARATE FORM FOR EACH TYPE S,Pf
riJ$ j n.s= l alit y
Facili Type/Grade:
Biological WWTP WW-ll Surface Irrigation
Physical/Chemical Land Application
Collection System R—,'Al Igh Regional Oe.-,
Operator in Responsible Charge (ORC)
Print Full Name: Mark R Haver
Certificate Type / Grade / Number: WW-4 990823 Work Phone #: ( 704 ) 361-0645
Signature: /�_(i"_', Date:
"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."
.................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Larry D Henry
Certificate Type / Grade / Number: VWV-2 24627 Work Phone #: (704 ) 361-0641
Signature: Gwl ,,7) 1 Date: // - S- l 9
"I certify that I agree to my designatio a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining t the sponsibilities 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 o lution Control System Operators Certification Commission."
..................................................................................................................................................
Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Email: certadminAmcdenn ov
Mail or fax a copy to the Asheville
Fayetteville
Mooresville
Raleigh
appropriate Regional Office: 2090 US Hwy 70
225 Green St
610 E Center Ave
3800 Barrett Dr
Swannanoa 28778
Suite 714
Suite 301
Raleigh 27609
Fax: [phone]
Fayetteville 28301-5043
Mooresville 28115
Fax: [phone]
Phone:[phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Washington
Wilmington
Winston-Salem
943 Washington Sq Mail
127 Cardinal Dr
585 Waughtown St
Washington 27889
Wilmington 28405-2845
Winston-Salem 27107
Fax:[phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Revised 02-2013

Facility Name: Memby Acres Permit #:
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Tommv C Caws
Certificate Type / Grade / Number: VNN-2 995695 Work Phone #: ( 704 ) 361-0657
Signature:-,...-� � Date:
"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.
.................................................................................................................................................,
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number: Work Phone #: ( L
Signature:
Date:
"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."
............................... :................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Work Phone #:
Date:
"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."
.................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Work Phone #:
Signature: Date:
"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."
.........................................................................................................................................................................
Revised 02-2013