WQ0023634_Other_20200225

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (�POCQ
NCAC 15A 8G .0201 NC016)1V
Press TAB to enter information 4, l'YR
Permittee Owner/Officer Name:
Email Address:
Currituck County/ Ben Stikeleather
Ben. Sti keleathercurrituckcoun nc. ov ry`?S�v�7r/ 4�a/i
tY 9 n.... 4r� y 1. _
�9a�,socto��a>
Permittee Signature: Date:- Qot;�
a -ate
Facility Name:
Waterside Villages WWTP
Permit # WQ0023634
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: WW
Print Full Name: Roderick Lee Hol
Certificate Type: WW
Facility Grade: III
ORC - OPERATOR IN RESPONSIBLE CHARGE
Certificate Grade: III
Email Address: [e-mail]
Signature:
Work Phone: [phone]
Certificate #: 1009155
Effective Date: 2 - 0 - 2-10
"1 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: William Donnell Orgsbon Work Phone: [phone]
Certificate Type: WW
Certificate Grade: IV
Email Address: Donnell. Orgsbon@currituck countync.gov
Certificate #: 1006384
Signature: u> ' ° % Effective Date: Z. - 2 5 - L C
"I certify that I agree to my designation as a Back-up Operator in Resp Bible 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."
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 28405-2845 Winston-Salem, NC 27105
Fax: [phone] Fax: [phone] Fax: [phone] Phone:
Phone: [phone] Phone: [phone] Revised 512019