NC0035904_ORC Designation Form_20170221

Water Pollution Control System Operator Designation Form
WPCSOCC
1vCAC 15A, $G .0201
'ermitteeOwner/Officer NaBle: William N. Stovall, PE, Director of Engineering
Mailbag Address: NC DPS Central Engineering, 4216 Mail Service Center
City: Raleigh State: NC zip: 27699 _ 4216 Phone #: [phone]
Email address: [e-mail]
Signature:
Facility Name: McCain Correctional Hospital Permit#:.NC003a904
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Faculty Tvne/Gr,de:
Biological WWTP X Surface Irrigation
Physical/Cherical Land Application
Collection System
Operator in Responsible Charge (ORC)
Print Full Name:
Philip W. Smith
Certificate Type] GrNumber:
Signature:
CENTRAL
FEB 21 2017
ENGINEERING
r
"I certify that I agree to my desigktion as e Operator in Responsible Charge for the facility noted. I undcrstand and will abide by the rules
and regulations pertaining to the responsibilities of the ORC as setforth in 15A NCAC 080 .0204 and failing to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
W-2 6038
944-2939
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:' Thomas Luther Criscoe
Certificate Type / Gra e / Number:
WW-2 990155 Wox1f Phone #: [phone] ext 350
Date: 2 -- ?
Work Phone #:
(910
Date:
Signature:
"I certify that I to my designation as a Back-up Operator in Responsible Charge for the faoility noted. 1 understand and will abide by the
rules and regulations pertaining to the responsibilities of the )3U ORC as Bet forth in 15A NCAC 080 .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]
original to: gmall _certadmin(oncdenr.g4Y
Mail or fax a copy 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; 828.296.4500 Fax: [phone] Fax: [phone] Phone:[phone]
Phone: [phone] Phone: [phone]
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 585 Waughtown St
Washington 27889 Wilmington 28405-2845 Winston-Salem 27107
Fax: [phone] Fax: [phone] Fax: [phone]
Phone: [phone] Phone: [phone] Phone: [phone]
Revised 03-2014