WQCS00018_ORC Designation Form_20210316

Water Pollution Control System Operator Designation Ffftllbpartment of
WPCSOCC Environmental Quality
NCAC 15A 8G .0201 Received
Permittee Owner/Officer Name: City of Eden Jon Mendenhall/City Manager MAR 15 2021
Mailing Address:
PO Box 70 Winston-Salem
Regional ce
City: Eden State: NC Zip: 27288 _ Phone #: [phone]
Email address: [e-mail]
Signature: Date: 3 �021
Facility Name: City of Eden Permit #: WQCS00018
County: Rockingham
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SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
Biological Collection Physical/Chemical Surface Irrigation Land Application
............................................................................................................................................
Operator in Responsible Charge (ORC)
Print Full Name: Michael Thomas Vernon Email: [e-mail]
Certificate Type / Grade / Number: CS/ 4/1009946 Work Phone #: [phone]
Signature:., -X2", Date:
"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 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 Responsible Charge (BU ORC)
Print Full Name: Byron Keith Curry Email: [e-mail]
Certificate Type / Grade / Number: CS/4/1007874
Work Phone #: [phone]
Signature: .L�i i`� -- i Date:
"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 WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
orieinal to: Email: certadmia(Zitedear.¢ov:
Mall orfax a cnny to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 E Center Ave 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax: [phone] Fayetteville 28301-5043 Mooresville 28115 Fax: [phone]
Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone]
Phone:[phone] Phone:[phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Revised 05.2015

WPCSOCC Operator Designation Form, cont.
Facility Name: City of Eden Permit #: WQCS0018
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Stephen Bradley Corcoran Email:
Certificate Type / G e / umber: CSd /1007053 Work Phone #: [phone]
Signature: / Date: 0j- L `/ — j i
"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."
.............................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Jesse David Carter Email: )[e-mail]
Certificate Type / Grade / Number: CS/3/1007055 Work Phone #: [phone]
Signature: � �R t - Date: 03 - I I " 202 (
"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."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Joshua Shawn Carter
Email: jscarter707@gmail
Certificate Type / Grade / n gr: CS/3/1007853 Work Phone #: 306
"I certify tlfat-I agree to my desig`nafion 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."
.............................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Mark Twain Bullins Email: [e-mail]
Certificate Type / Grade / Nuumber: CS14./27633 Work Phone #: [phone]
Signature: Lj�, / ?��AA� Date:-0
"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."
Revised 05-2015