NC0035904_ORC Designation Form_20071108

DEC-18-2007 11:36 SANDHILLS MAINTENANCE
P.01/01
Water Pollution Control System Operator Designation Form
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NCAC 15A 8C .0201
NC DEPT OF CORRECTION
Permittee Owner/Officer Name: , Mr . G . J . Freeman, P.E.
4216 MSC, Central Engineering Div.
Mailing Address:
City: Raleigh State: NC Zip: 27699-4216
Signature: �.
Phone #: [phone]
Date: 11/08/2007
McCain Correctional Hospital
Facility Name:
WQ0010490
Permit #:
! SUBMIT A SEPAkATE FORM FOR EACH TYPE OF SYSTEM !
Facility Type & Grade:
Biological WWTP
Physical/Chemical
Collection System
Type Grade
Surface Irrigation
Land .Application
Type
Grade
N/A
503 N/A
Operator.in Responsible Charge (CRC)
Print Pull Name: into/NIA s 1 yr H ER
Certificate Type / Grade /Number: Work Phone t>{: ( )
Signature: _ Date:
"I certify that 1 agree to my designation as theOperater 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 Co tunission."
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Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: S QTJi ( /SCV
Vtrin/I-98G/83
Certificate Type / Grade / Number: qR6 S 86
Signature:
Ave
Work Phone It: (9/Q) 2` 81 - 3 / C /
Date: /A2f/3/O7
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility floted, 1 understand and will abide by
the rules and regulations pertaining to the ro3ponsibilities 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 or Fax to:
Fayetteville Regional: Office
225 Green St. Suite 714
Fayetteville, NC 28301-5043
14
CENTRAL
OCT 1.5 2007
Fax:[phone]
See next page for designation of additional back- operators. Designation of more than one back-up operator is o rianal. ENGINEERING
PS Bn �P A b" P P A
Revised 8-2007
TOTAL P.01
WPCSOCC
1,618 Mail Service Center
Raleigh, NC 27699-1618
Fax; 919/733-1338

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Water Pollution Control. System Designation Form 10 -;1 -
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NCAC 15A:08G .0201 1-1
General Information:
Permittee Owner/Officer Name:
Mailing Address:
City: State: Zip:
Telephone Number: ( )
Signature: Date:
Facility Information:
C i � . C'. S?
Facility: a �' f �C c eN� 14 n f
Permit Number: NC... 003 S 9 0/4 County: 17 6 k e_
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM !
Mark (X) Type of Facility Class (1 — 4)
Wastewater Plant
Physical/Chemical
Collection System
Class
Spray Irrigation N/A
Land Application N/A
Subsurface N/A
Operator in Responsible Charge: ,-
Print Name: D�.r� e-\ �� L�'(tv ( Social Security ## : 2 4-0 4' 3 6 7lT
Certificate Type and Grade: LijoiateiticeSeTG r. It Certificate #: q 6 9
C� �g,L4"7351 Signature:
Work Telephone: (t � ) -1 T gn '� !-Q
Back -Up Operator in Responsible Charge:
�- 51
Print Name: �}'10 YES 1..0 r l_�" 1 SC.I� L. Social Security. # S 8 a 1)
Certificate Type and Grade: a-A.i...Q.WcStr G% Z Certificate #: -1 $ I 1 V.5
Work Telephone: (CI ID) )211`' 3 to \ Signature.��%L✓c?'t'� 2 .
Mail or Fax to:
WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]
Revised 10/2000

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