NC0088366_Operator Designation Form_20121031

2012/11/01 12:15:28
Signature:
Water Pollution Control System Operator Designation Fold
WPcsocc
NCAC 15A 8G .0201
Permittee Owner/Officer Name:
Mailing Address: P. D. eD,,.o3t
i \ c1.
City: L. i ItV1614) $can State: J c Zip: 7 -5%. -
Email address:
Signature:
Phone #: ( I)) 3 ~'7575' tx 36 L/Z.
Date: //- /— "--
Facility Name: 6-4:9'*h I-60724fr Cect -y getlic9,74 Vitktre Permit ##:Re0Pg:366
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade:
Biological WWTP IOW Surface Irrigation
Physical/Chemical Land Application
Collection System
Operator in Responsible Charge (ORC)
Print Full Name:. ! um') 6 a r.r a_ 1. G c rP1 P.d rez.,
Certificate Type / Grade / Number: \°,IW 'IV (* 2 g
,.
•
Si�ature:
Work Phone #: Ito ' Op Q- -6
Date: f o —
"I certify that agree to my designanon as the Operator is Responsible Charge for the facility noted. I understand and will abide by therules
and regulations pertaining to the responsibilities of 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 Q3U ORC)
Print Full Name: CIr '5 • MDTrr t 5 t o in-tcut
Certificate Type // Grr e /Nurnbe W �( � (1 V. Work Phone #: ( iU) 4 3()
At.4114,1 Date: / C'' -31 "
"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 setforthin 15A NCAC 08G 40205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification.Commission."
:Mil or fax the original to:
WPCSOCC, 1618 Matz Service Center, Raleigh, NC 27699-1618
Mail or faxn copy to the Asheville
2090 US Hwy 70
Swannanoa28778
Fax: [phone]
appropriate Regional Office:
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: 910A86.0707
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Mooresville
610E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Fax: [phone]
Winston-Salem
585 Waughtown St
Winston-Salem 27107
Fax: [phone]
Raleigh
3800 Barrett Dr
Raleigh27609
Fax: [phone]
Revised 6-2012

2012/11/01 12:15:28 4 /4
Facility Name:. O ( - 1-4-Y lit.'-
Back -Up Operator in Responsible Charge (BU:ORC)
Print Full Name: / ,/U�
Permit #: I'j!: ae 36.C.
Any 7d
Certificate Type / Grade / Number: 1.1/W J S G e 3 ;C Work Phone #: (/e') b"/ Il
Signature:
lrl:>
Date: / f - z 3' - 2-‘'!d'-
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facilitynoted. I understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC asset faith in 1 SA NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions. by the Water Pollution Control System.Opeiators Certification Commission."
Back -Up Operator in. Responsible Charge (BU ORC)
Print Full Name: Q/?t "Avir ipelir,eramety
Certificate Type / e / Number: -tea WorkPhone #:
Signature: / - � � �.,'rr��— Date:
(110:) 81//
/O- 25=26.12,
"I certify that I agree tir>gy designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide bythe
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:
Certificate Type / Grade /Ntunbe^ t - ) `f
Signature;
E3es.6t 6
Work Phone #: (9/Ci `.2 V C.:5C/ V76
Date: :1// %/ 7,
1 certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and win abide by the
rules and regulations pertaining to the responsibilities of the BTJ 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)
PrintFuli Name:
Certificate Type / Grade l Number: Work Phone #: ( )
Signature: Date:
"1 certify that! agree to my designation as a Back-up Operator iri 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 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 6-2012

2012/11/01 12:15:28. •1 /4
Harnett
COU N TY
NORTH CAROLINA
www.harnett.org
Subject:
ORC Designations for SHRWWTP NC 0088366
From: Vicky Payseur
Phone: 5481
P
Address:
- Fax:
DENR-FRC
NOVO1 2012
D wo
Number faxed to: 4860707
n
12:15:28
2012-11-01 4

2012/11/01 12:15:28 2 /4
Vicky Payseur, Pretreatment Coordinator
Harnett County Department of Public Utilities
PO Box 1119
Lillington, NC. 27546-1119
Phone: [phone] ext 5481
E-mail: [e-mail] <mailto:[e-mail]>