NC0003760_Operator Designation Form_20210308

Mar. 8. 2021 12:39PM
No.6709 P. 1/1
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC) *ce,
NCAC 15A 8G .0201
Permittee Owner/Officer Name:
Email Address:
Permittee Signature:
Press TAB to enter Information
George T. Xenakis
[e-mail]
Facility Name: Dupont Industrial Biosciences USA LLC
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: WW-IV
Date:
Permit
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Print Full Name:
Certificate Type: Select
Email Address:
Signature:
"I certify that i agree to my designation as the Operator in Responsible Charge for the facility noted. 1 understand and will abide by the
rules and regulations pertaining to the responsibilities of the ORC as set forth in ISA NCAC 08G .0204 and falling to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Certificate Grade: Select
Work Phone:
Certificate #:
Effective Date:
'T E°ST f t w
Print Full Name: David Lawton Suggs
Certificate Type: WW
Email Address: david.I.SU
Signature:
Certificate Grade: III
[e-mail]
Work Phone:
Certificate #:
Effective Date:
252-559-7002
1010109
3-9 2 /
certify that 1 ogree to my designation as a Back-up Operator in Responsible Charge for the facility noted. 1 understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in ISA NCAC 08G .0204 and falling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission,"
Mall, fax or email
ORIGINAL to.
Mall or Fax a COPY to:
WPCSOCC, 1618 Mall Service Center, Raleigh, NC 27699-1618
i• cc
Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax;828-299-7043
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
fax: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone; 910-433-3300
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax; 910-350-2004
Phone: [phone]
Mooresville
610 E. Center Ave.. Suite 301
Mooresville, NC 28115
Fax; 704-663-6040
Phone: [phone]
Winston-Salem
45 W. Hanes MIII Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone; 919-791-4200
Revised 1112020