NC0023353_Operator Designation Form_20020703

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TOWN OF WHITE LAkE
Water Pollution Controfi System Designation Form
'WPCSOCC
NCAC 1SA:08G .0201
General Information:.
. .
Pernninee Owner/Officer Name:
Ivisailing, Address:
re")to/i C it!'7". Liqc F.
WI /4"/C6 • . State; /1- Zip: :2-?1.7753
Telephone Number: ( 9/0 ) ,86 152%0
Signature: -
Da e: 7 - ec, -- 2—)
.opommpco.couoncousacoosomaomompapappoomonommoqmo=pumompoguaocielacagapc10.0.$
FmcilitylnfortmationFacility:
. • *Permit Number. 4/le c...2 0 ;2 3 .3
County: Beerd.41._)
SUBMIT A SEPARATE FORM FOR EACH TYPE
• •
mar% (X): TvDeofUty Class. — 4)
Wastewater Plant X
Physi./Chemical
Collection System
F SYSTEM !
Spray Teri patina
• Land Application
• Subsurface
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N/A
• ISL..
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apoavoomuamt2apoacaommommumomuummappeommtamasnomenwaaosesameaVE104008900111 :
Operator in Responsible Charge:
Print Name: e5i1 5±4FFOR
• Certificate TyPe and Grade:
ocial• Security i4 : • -70 .47 6-
6124 Pe j. Oj 1..4-). Certificate #: ;75'7; 6•‘)
. Work Teieplaone: /tC)) g6;2-1,4)c) Signature:
•
•
WrAUC00r0000003013000000051312,120EIPEI02000000IS0a00001,670=1;1213aq000000033•8000e
Back.Up operator in ResponsibleCharge:
PtNa: 0 [itje ra 4-11-) Social.Security
Certificate Type and Graz: C-11413 &i11
Work Telephone': (9e ) a.;?-e5Z):3 signatur:
Mail or Fax to: tVPCSOCC
1618 Mail Service Center
Raleigh, N.C. 21699-1618
Fez: 9191733-1338
S:OI MOZ 2 PC
2.38 1
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Certificate A.? 3 s'/
/14V"
.7 .
441, c, 3-050
Revised 10f2000
rifr9X - :5/6% -0 747
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61.-J24-4
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N.C. WATER POLLUTION CONTROL SYSTEM OPERATORS
CERTIFICATION COMMISSION
GRADE CERT. NO.
•
is a duly Certified Water Polrutio'n.Control System Operator under
1 provisions of Article 3, Chapter 90=A'of the General Statutes of North
Carolina for the year:
-
CHAIRMAN
SIGNATURE OF OPERAT((SEE REVERSE SIDE)
2002 `des
3)1U1 31I HP1 30 NM01
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