WQ0006941_ORC Designation_20181023

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC I5A 8G .0201
Permittee Owner/Officer�Name: ,
Mailing Address: ya 6 ox /Zo U
+c42-i- rasciusti Ca scltao/s
City: )764Ce yd/Ve. State: A.IC Zip: a379-
r I - Phone #: ( )
Email address: Ihrrh41e4&Ce. s!ram-f(,/<(2,/jC,us
Signature: !%7L�. ` //,3 IC
Facility
Date:
eS-�a/le/ Cite ,E �,(, 144It /re Permit#: (A)Q dC0(0g5t(
SUBMIT A SEPARATE FORM FOREACH TYPE SYSTEM!
Facility Type/Grade:
Biological WWTP
Physical/Chemical
collection System
Surface Irrigation
Land Application
Lz
Operator in Responsible Charge (ORC)
Print Full Name: /i�r/j/// j/'t C51--
Certificate Type / Grade / Number: S= — 7 73 / Work Phone #: (33 (a ??6 " 2 8-51.
Signature: Date: /O -ZZ ' / Si
"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 I5A 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 Responsi• e Charge (BU ORC) /
Print Full Name: eA ( eb (97(74k
Certificate Type / Grade / Number:
Signature:
(A)Ok)- (- 770
Date:
(336-) 976 • Z 1
/Q-2a-(x
"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."
Mail, fax or email the
original to:
Mail or fax a copy to the
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center,
Email: eertadmin(aincdenrgov
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Raleigh, NC 27699-1618 Fax: [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 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
585 Waughtown St
Winston-Salem 27107
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 03-2014