NC0038997_Correspondence_20200623

JUN/23/2020/TUE 01:07 PM R & A Labs FAX No.3369960326 P.001/001
Water Pollution Control. System Operator Designation Form
W13CSOCC
NCAC 15A 8G •0201
Permitter Owner/Officer Name:
Mailing Address: _ 2!d t a q
City: r State: {{Ai G Zip: 29' ._jit ✓
Email address' 11 i'QYId ig la ki5 e pt b!(t op k
Signature:_
Phone #: (33 6) q%_ 28y/
u
Facility Name: ;^ 2/` t��p /yV ...../itlG�. :.. Permit #: .KILO-() . 3 $17212
STJBMFT A SEPARATE FORM FOR EACH 'TYPE SYSTEM!
Facility yne/Grrade_
BiologicalWWTP _ ' SufaceLTigation
Physical/Chemical Land Application
Collection System
Operator in Responsible Charge (ORC)
Print Full Name:
Certificate Type / Grade / Number:: ` 2 Work Phone #:
Signature: Date:
" 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 Operetots Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number: VW Work Phone #: (,33(P) of of � � L% Z
r
Signature: -'Date; 6P
"I certify that I 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 BU ORC as set forth in 15A NCAC 080 A205 and Ming to de so can result in
Disciplinary Actions by the Water Pollution Control System Operators Celtif cation.Commisaion."
Mai! ax or enatl the WPCSQCC 1 618 Mail Service Center, 12,aleigbr NC 27699-1618 Fax: [phone]
original to: -all. pertadmin(¢}ncdeni.goW
Mail or fax a copy to the Asheville
appropriate Regional Of)`ice: 2090 US Hwy 70
Swannatma. 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington SgMall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Chen St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilnvggtoo
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: 910,796.7215
Mooresville
610 E Ceuter Ave
State 301
Mooresville 28115
Fax: [phone]
Phone:[phone]
Winston-Salem
585 Waughtown St
Winston-Salem 27107
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dt
Raleigh 27609
Fix:919.571.4718
Phone:[phone]
Revised 02-2013