NC0035904_ORC Designation Form_20080724

Michael F. Easley, Governor
July 24, 2008
North Carolina Department of Correction
CENTRAL ENGINEERING DIVISION
2020 Yonkers Road °4216 MSC ° Raleigh, NC 27699-4216
Mr. Jerry F. Rimmer, Supervisor —
Technical Assistance & Certification Unit
NC DENR Division of Water Quality
1618 MSC
Raleigh, NC 27699-1618
RE: Water Pollution Control System ORC Designation Forms
NC00359,04 DOC McCain Correctional Hospital #3700
WQ0010490 DOC McCain Correctional Hospital #3700
Dear Mr. Rimmer:
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Theodis Beck, Secretary
Attached please find the above referenced updated WPCSOCC forms. Following your review please let
me know if you require any additional information.
Thank you for your assistance with this matter.' Please call me in Raleigh at 716-3433 or email me at
hkg02 !_,doc.state.nc.us at your convenience if you have any questions.
Respectfu
enneth G. Hart
Facility Engineering Specialist
Attachments: 2
pc:
DENR Fayetteville Regional Office 225 Green St. Suite 714 Fa etteville
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Telephone [phone] ° Fax [phone]
An Equal Opportunity / Affirmative Action Employer
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C. 28301-5043

Facility Name:
Permit Number:
Water Pollution Control System Designation: Form
WPCSOCC
NCAC 15A:08G .0201
General Information:
G. J. Freeman, P.E., Director of Engineering
PermitteeOwner/Officer Name: NC DOC, Central Engineering Div.-
Mailing Address: 4 216 MSC
City. Raleigh State: NC Zip:27699-4216
Telephone Number ( 919 ) 716 - 3 4 0 0 Fax Number (919 ) 716 - 3 9 7 8
Signature:
Date: 7/2" % D
Facility Information: -
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County:
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! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM !
Mark (X) Type of Facility Grade Mark (X) Type of Facility
Wastewater Plant
Physical/Chemical
Collection System
Spray Irrigation
Land Application
Operator in Responsible Charge:
Print Name: r \ 1 IQL:(S"-1` Q--
Certificate Type and Grade: LG(. ppi;C•ctAn Certificate #: 2_2-Ti 3 L
Work Telephone: (9/ G) 9 7 %S 33 _ Signature:.' / ?
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Back -Up Operator in Responsible Charge:
Print Name: f d/ w.5 . (i (k-i
r- f
Certificate Type and Grade: tA,1 L/ 2 /L./4w® ,f PP, Certificate #: 9)g-gSO L
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Work Telephone: (q7O) p��'j / - 3/ / Signature: 'X ) f,ci� ei
Mail or Fax to:
WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]

Water Pollution Control System Designation Form
WPCSOCC
NCAC 15A:08G .0201
General Information:
• G. J. Freeman, P.E.,•.Director of
Permittee Owner/Officer Name: NC DOC, Central •Engineering Div.
Engineering
Mailing Address: 4 216 MSC
City:- Raleigh State: NC Zi 27699-4216
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Telephone .hone Number- 919 716-3400 919 716-3978
( ) Fax Number ( )
Signature: J
Date:
Facility Information:
Facility Name: 11 a C-A,;\I-N f i• ri• kNAJTP
Permit Number: N C- O ©3 Sm`i 0 County: ) fo kg—
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM !
Mark (X) Type of Facility Grade
Wastewater Plant ) 2
Physical/Chemical
Collection System
Mark (X) Type of Facility
Spray Irrigation
Land Application
Operator in Responsible Charge:
Print Name: 1 ` 1 re_C b 0 e—
Certificate Type and Grade: W Gr c & .
Work Telephone: (9/9) 3c4T - Z33 0 Signature:
Certificate #:
..
151,/,
Back -Up Operator in Responsible Charge:
Print Name:
Certificate Type and Grade: kit) W 1- Certificate #: 0.. /$.3
Work Telephone: (9/0 ) Sid/ Signature:
Mail or Fax to:
WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]
NI .I