NC0081825_Operator Designation Form_20160222

02/29/2016 17:33 7048268404
TOWN OF ANSONVILLE
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Water Pollution Control System Operator Designation Form
WPGSOCC
NCAC 15A 8G .0201
Pernlittee Owner/Officer Name:
Mailing Address: `` .)
City: J 1\\ State:}. Zip: C(3 ) Phone #: &-(D
Ettiail addres
Signature:
\\V, Esio-ztc\v_
Facility Name:3W,S
Date:
Permit#:
SUBMIT A SEPARATE FO.ti1VI FOR EACH TYPE SYSTEM!
Facility Type/Grade:
Biological WWTP
Physical/CbeinicaI
Collection System
V f
V \ t
Surface lmigation
Land Application
Operator in Responsible Charge (ORC)
Print Full Name: �t Q� C ,N \+\\S
Certificate. Type / C'rade /N tuber: i• ;�. CNc..,.'1A Work Phone #: na4',
Signature: Date:
"1 certify that I agree to my designation a.'the 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."
Sack -Up Operators in Responsible Charge (BIJ ORC)
Print Full Name: art, ty).a -
Certificate Type. / Grade / Number: w w 1 .. Uz,z., Work Phone #: - "C'S
Signature: �- f Date:
"1 certify that 1 agree to my designation as a Flack -up Operator in Responsible Charge for the facility noted. 1 understand and will abide by the
r l s and regulations pertaining to the responsibilities of the BU ORC. as set forth in 15A. NCAC 080 .0205 and failing to do so 'ear) result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail or fax the original to: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
Mail or fLv a copy to the Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
appropriate Regional Office:
Washington
943 Washington Scl !viall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 T. Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
585 Wau htown St
Winston-Salem 27107
Fax: [phone] "
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 10-2012