NC0081825_Operator Designation Form_20130206

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PO BOX 437
ANSONVILLE NC 28007
PHONE/FAX: [phone]
FAX
Town of Ansonville
To: WPCSOCC Form - From: Dianna McLaughlin
Pax: 910-466-0707 Pages: 2
Phone:
Date: February 6, 2013
Re: CC:
0 Urgent 0 For Review C] Please Comment ❑ Please Reply ❑ Please Recycle
Attached is the Water Pollution Control System Operator Designation form for the Town of Ansonville.
If further information is needed, please to not hesitate to contact me.
Sincerely,
Dianna McLaughlin
Town Clerk
Town of Ansonville
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Water Pollution Control System Operator Designation Form
wPcsocc
NCAC 15A 8G 0201
Fermittee Owner/Officer Name L`t„no-4
Mailing Address:
City.1�—'�c�r
Email address:J.cts\r-,,
Signature:`
State: )mil - Zip: a` - Phone #:. () 8 ac,p- .2;.4O
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'Facidity Name: Chet\ f -�jY S a`\k ' Permit #: 1 g
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Tyne/Grade:
Biological W°WT? t Surface Irrigation
Physical/Chemical Land Application
Collection System
Operator in Responsible Charge (ORC}
Print Full Name: k1t\‘1`0..' . 0,3.Qit 11
Certificate Type / Grade /Number: %1 VPi - 5 3 Work Phone #: ( U) % `9 A
Signature:,!
Date:
*-0
"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 08Q _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: tee _gratCy / Zl&'Sy
Certificate Type / Grade / Number: 'V4 C/`S t W 1) rho- Work Phone #R04 ) TS5D. CO • (`-
Signature:
.Date: .AS\\121OS3
"I certify that I agree to my designation as--a.".1-3;c1C-til--ix,perator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities oftiie BU ORC as set forth in 15A NCAC 080.0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Conunission."
Mali or fizz the Original to: WPCSOCC, 1618 Mali Service Cvnter, Raleigh, NC 27699-1618 Pax: 019.807.6492
Mail or fax a copy to the Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
appropriate Regional Office:
Washington
943 Washington Sq M:r11
Washington 27889
Fax: 252.946,9215
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 B Center Ave
Suite 301
Mooresville 28115
Fax. /04.663.6040
Phone: /04.663.1699
Winston-Salem
585 Waughtown St
Winston-Saletn 27107
Fax: 336,771.4631
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27600
Fax: 919.571,4718
Phone;919.791.4200
Revised 10-2012
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