WQ0000731_Application_20210512

Anchor QEA of North Carolina, PLLC
231 Haywood Street
Asheville, North Carolina 28801
828.281.3350
State of North Carolina
Department of Environmental Quality
Division of Water Resources — Non -Discharge Branch
1617 Mail Service Center
Raleigh NC 27699-1617
Re: 15A NCAC 02U — Reclaimed Water System — Renewal
Form: RWS-R 02-21
Supplementary Information to Permit No. WQ0000731
To Whom It May Concern,
ANCHOR
QEA
May 12, 2021
On behalf of the Lake Toxaway Company, Anchor QEA of North Carolina, PLLC, is pleased to provide this
Reclaimed Water System permit renewal application for Permit Number WQ0000731 to the Division of
Water Resources. This letter provides additional information to supplement the attached Reclaimed
Water Systems - Renewal (Form: RWS-R 02-21).
ATTACHMENT H—AFFILIATIONS
Make the following corrections:
Persons with Signature Authority
Kenneth S McCall, correct email address from smccall@ipm corp.com to [e-mail].
Designated Operators: Facility Classification SI
Per the attached Water Pollution Control System Operator Designation Form, remove Thomas W
Kilpatrick to replace with:
Operator Name
Role
Cert Type
Cert Status
Cert #
Effective Date
Danielle Ann Hunter
Backup
SI
Active
1007992
5/1/2021
Designated Operators: Facility Classification WW2
Per the attached Water Pollution Control System Operator Designation Form, remove Thomas W
Kilpatrick.
RWS-R-02-21_Lake Toxaway_2021-05-03_Cover Letter.docx

May 12, 2021
Page 2
ATTACHMENT I —COMPLIANCE SCHEDULES
The following compliance schedules are included in permit WQ0000731, dated May 24, 2016, and have
been addressed as discussed below.
1. An evaluation of existing wet weather storage capacity shall be completed no later than
December 31, 2016. The results of the evaluation shall be prepared by a licensed North Carolina
Professional Engineer and submitted to the Division by March 31, 2017. At that time, this permit
may be modified to include a compliance schedule for completion of the approved changes [15A
NCAC 02T.0108(b)(1)].
Response, including documentation that the compliance schedule has been met:
Per the compliance inspection report performed on July 6, 2018, by the North
Carolina Division of Water Resources and submitted to Lake Toxaway Company on
August 3, 2018:
Anchor QEA of North Carolina submitted the wet weather storage pond evaluation
on June 18, 2018, as required by permit condition 1.1. An extension request for
submitting any plans for modifications to the ponds until December 31, 2018, was
approved by the North Carolina Department of Environmental Quality (DEQ). The
evaluation showed the following:
1. The 5-day pond provides 39,789 gallons of storage and the irrigation pond
provides 165,013 gallons of storage. (Both volumes differ from what is given in
the current permit.)
2. Both ponds should be relined.
3. The water balance, available acreage, and a history of successfully managing
the irrigation system, indicated that the current pond volume is adequate.
2. No later than six months prior to the expiration of this permit, the Permittee shall request renewal
of this permit on official Division forms. Upon receipt of the request, the Division will review the
adequacy of the facilities described therein, and if warranted, will renew the permit for such
period of time and under such conditions and limitations as it may deem appropriate. Please note
Rule I5A NCAC 02T .0105(d) requires an updated site map to be submitted with the permit
renewal application [15A NCAC 02U .0106, 02U .0109].
Response, including documentation that the compliance schedule has been met:
This compliance schedule has been met by this letter and attached Reclaimed
Water Systems - Renewal (Form: RWS-R 02-21). An extension request for

May 12, 2021
Page 3
submitting the permit renewal application until mid -May 2021 was approved by
the North Carolina Department of Environmental Quality (DEQ) on April 28, 2021.
Conclusion
Please contact me at 828-281-3350 or [e-mail] if you have any questions.
Sincerely,
Robert Cork, PE MEng
Managing Engineer
Attachments
Figure 1 Site Location Map
Figure 2 Existing Spray Areas
Figure 3 Treatment Plant
Attachment 1 Reclaimed Water Systems - Renewal (Form: RWS-R 02-21)
Attachment 2 Water Pollution Control System Operator Designation Forms

Parcel Boundary
Service Layer Credits:Transylvania County GIS,
Copyright:© 2013 National Geographic Society, i-
cubed
ALTAMONT ENVIRONMENTAL, INC.
ENGINEERING a 1"1 f 04UGEOLOG'r
231 Hn,wOGi, E1'k!fr. Asi,e,il.l. NC 2E801
TeL.825=81.2350 r. C.82B Y41 33E51
www- =am
DRAWN BY: COREY CARPENTIER
PROJECT MANAGER: BRIAN GANT
CLIENT: LAKE TOXAWAY CO.
DATE: 7/6/2016
Scale Feet
0 1,000 2,000
SITE LOCATION MAP
Lake Toxaway Country Club
4366 North Club Boulevard
Lake Toxaway, North Carolina
FIGURE
1
P:\Lake Toxaway Country Club\Sewage Treatment Plant\Permitting \O & M Plan\Figure 1.mxd

\LY / \ /
y �
FAIRWAY
12
/
/
FAIRWAY 14
LEGEND
SETBACK BUFFERS AND DRINKING WATER SUPPLY
UNSUITABLE SOILS WELLS
PROPERTY BOUNDARIES
PROPOSED SPRAY
IRRIGATION ZONES
SURFACE WATER BODIES lk O BUILDINGS
SITE TOPOGRAPHY
ALTAMONT ENVIRONMENTAL, INC.
'ENGINEERING & HYDROGEOLOGYI
231 Haywood Street, Asheville, NC 28801
TEL.[phone] FAC.828.281.3351
www.altamontcnvironmental.com
DRAWN BY: CHRIS GILBERT
PROJECT MANAGER: STU RYMAN
CLIENT: LAKE TOXAWAY COUNTRY CLUB
DATE: 6/13/07
SCALE (FEET)
250 0 250 500
EXISTING SPRAY AREAS
LAKE TOXAWAY COMPANY
LAKE TOXAWAY,
TRANSYLVANIA COUNTY, NORTH CAROLINA
FIGURE
FILE PATH: P:\LAKE TOXAWAY COUNTRY CLUB\FIGURES\CAD\HOLES I-9\PERMIT PACKAGE\ FISURE2 - EXISTING SPRAY AREAS.DWG

IRRIGATION HOLDING POND
UNDAR
'.
DETENTION POND
AERATED
SURGE TANK
EXTENDED
AERATION UNITS
TERTIARY FILTER AND
CHLORINE CONTACT TANK
SOURCE:
AERIAL PHOTOGRAPHY AND
PROPERTY BOUNDARIES
FROM TRANSYLVANIA GIS
ACCESSED FEBRUARY 15, 2007.
ALTAMONT ENVIRONMENTAL, INC.
50 COLLEGE STREET. ASHEVILLE. NC 28801
Tel. [phone] Fac. 828.281.3351
www.altamoutenvirmunental.com
50 25 0 50 100
• • •• • • • • • •
••
• • • . •
3
..............
G:\Proposals\Lake Toxaway\GIS\FIGURE3-TREATMENT PLANT.mxd

DWR.
Division of Water Resources
State of North Carolina
Department of Environmental Quality
Division of Water Resources
15A NCAC 02U - RECLAIMED WATER SYSTEM - RENEWAL
FORM: RWS-R 02-21
Pursuant to 15A NCAC 02T .0107(b), if the application does not include all required information and the necessary
supporting documentation, the application shall be returned. The application and attachments shall be prepared in
accordance with 15A NCAC 02T .0100, 15A NCAC 02U, and Division Policies. For more information, visit the Water Quality
Permitting Section's Non -Discharge Branch website. The Applicant shall submit an electronic copy of the application and
attachments uploaded as a single Portable Document Format (PDF) file to https://edocs.deq.nc.eov/FormslNonDischaree-
Branch-Submittal-Form-Vert, or mailed to Non-Discharge.ReportsQncdenr.gov if less than 20 megabytes (MB).
SECTION I - APPLICANT INFORMATION
. Applicant: Lake Toxaway Company
2. Permit No.: WQ00731
• Signature authority: Reginald Heinitsh Title: Chairman of the Board
Phone number: [phone] Office Email: [e-mail]
. Mailing address: 100 Waterfall Circle
City: Lake Toxaway State: NC Zip: 28747-
Contact person: Scott McCall Email: [e-mail]
Primary phone number: [phone] Office Secondary phone number: [phone] Cell
SECTION 11-- FACILITY INFORMATION
1. Physical address: 4366 West Club Blvd County:
Transylvania
Parcel No.:
City: Lake Toxaway State: NC Zip: 28747-
2. Treatment facility coordinates to the sixth decimal degree:
Latitude: 35.137775' Longitude: -82.960747° Method: Aerial photography with ground control
SECTION III - FLOW INFORMATION
1. Permitted flow: 20000 GPD (The maximum allowable flow based on what has been permitted)
2. As -built flow: 21600 GPD (The maximum allowable flow based on what has been constructed)
3. Average flow: 5840 GPD (The average of all reported flows on the previous calendar year's NDMRs)
4. Hydraulic capacity: 27 % (Divide the average flow in Item 3 by the As -built flow in Item 2)
5. Wastewater composition: Domestic : I00 % Industrial: % Stormwater: %
t
SECTION IV - BILLING INFORMATION
1. Billing address: PO Box 570
City: Lake Toxaway State: NC Zip: 28747-570
2. Verify the Applicant does not have any overdue annual fees:
https://deq.nc. Qov/about/divisions/water-resourcesiwater-resources-permitsi wq-enavments
Pursuant to 15A NCAC 02T .0120(c), permits for renewing facilities shall not be granted if the Applicant or any affiliation has
an unpaid annual fee.
FORM: RWS-R 02-21 Page 1 of 6

SECTION V — OPERATOR IN RESPONSIBLE CHARGE (ORC) INFORMATION
(NOT APPLICABLE FOR CONJUNCTIVE SYSTEMS)
1. ORC: Gary Dennis Norton
Mailing address: 128 Maple Hill Road
City: Penrose
Phone number: [phone] Office
Grade: WW-2/SI Certification No.: 29126/21853
State: NC Zip: 28766-
Email: [e-mail]
2. Back -Up ORC: Danielle Ann Hunter
Mailing address: 1 I Nicholson Lane
City: Etowah
Phone number: [phone] Select
Grade: SI Certification No.: 1007992
State: NC
Zip: 28729-
Email: [e-mail]
SECTION VI — OPEN -ATMOSPHERE STRUCTURES
1. List all open -atmosphere treatment and storage structures associated with the renewing permit. Attach additional sheets if
necessary.
Type
Parcel No.
Volume (gal)
Liner Type
Freeboard (ft)
Latitude
Longitude
5-Day Upset
8513-60-2141-000
39,789
Full, synthetic
2
35.137800°
-82.960911°
Storage
8513-60-2141-000
165,013
Full, synthetic
2
35.137805°
-82.961276°
Select
Select
. °
- °
Select
Select
0
- 0
SECTION VII — RELATED PERMITS
1. List all wastewater permits (i.e., sewer, collection system, NPDES, residuals) that have interactions with the renewing permit.
Attach additional sheets if necessary.
Permit Type
Permit No.
Relationship Type
Select
Select
Select
Select
Select
Select
Select
Select
SECTION VHI — MONITORING WELLS
1. List all groundwater monitoring wells associated with the renewing permit. Attach additional sheets if necessary.
Well Name
Parcel No.
Status
Gradient
Location
Latitude
Longitude
Select
Select
Select
°
- 0
Select
Select
Select
. °
- 0
Select
Select
Select
°
- 0
Select
Select
Select
. °
- 0
Select
Select
Select
. °
- 0
Select
Select
Select
°
- 0
Select
Select
Select
°
- . °
Select
Select
Select
. °
- . °
Select
Select
Select
. 0
- 0
Select
Select
Select
. 0
- 0
FORM: RWS-R 02-21
Page 2 of 6

SECTION IX — UTILIZATION FIELDS
1. List all utilization fields associated with the renewing permit. Attach additional sheets if necessary.
Field
County
Parcel No.
Deeded Owner
Area
Cover Crop
Latitude
Longitude
02-DR-01
Transylvania
Lake Toxaway Co.
2
Golf course
35.137500°
-82.953611°
02-FW-
11
Transylvania
Lake Toxaway Co.
2
Golf course
35.147222°
-82.949722°
02-FW-
12
Transylvania
Lake Toxaway Co.
2
Golf course
35.131944°
-82.949444°
02-FW-
14
Transylvania
Lake Toxaway Co.
2
Golf course
35.129167°
-82.947500°
02-FW-
15
Transylvania
Lake Toxaway Co.
2
Golf course
35.130833°
-82.951389°
02-FW-
16
Transylvania
Lake Toxaway Co.
1
Golf course
35.131667°
-82.953889°
02-FW-
17
Transylvania
Lake Toxaway Co.
2
Goff course
35.132222°
-82.956667°
02-FW-
18
Transylvania
Lake Toxaway Co.
3
Golf course
35.135833°
-82.955556°
02-T-10
Transylvania
Lake Toxaway Co.
1
Golf course
35.137500°
-82.953611°
02-T-1 I
Transylvania
Lake Toxaway Co.
2
Golf course
35.136667°
-82.951389°
02-T-17
Transylvania
Lake Toxaway Co.
2
Golf course
35.131111 °
-82.954722°
02-T-18
Transylvania
Lake Toxaway Co.
1
Golf course
35.134167°
-82.956111°
FW1 and
9
Transylvania
Lake Toxaway Co.
2
Golf course
35.138333°
-82.956111 °
FW2
Transylvania
Lake Toxaway Co.
1
Golf course
35.140833°
-82.959722°
FW3
Transylvania
Lake Toxaway Co.
3
Golf course
35.143056°
-82.958333°
FW4
Transylvania
Lake Toxaway Co.
1
Golf course
35.144722°
-82.961667°
FW6
Transylvania
Lake Toxaway Co.
I
Golf course
34.142222°
-82.962778°
T3 and 8
Transylvania
Lake Toxaway Co.
1
Golf course
35.141667°
-82.960556°
T5
Transylvania
Lake Toxaway Co.
2
Golf course
35.144444°
-82.963333°
T6
Transylvania
Lake Toxaway Co.
1
Golf course
35.144167°
-82.962222°
T7
Transylvania
Lake Toxaway Co.
1
Golf course
35.140833°
-82.962222°
0
0
0
0
°
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
FORM: RWS-R 02-21
Page 3 of 6

a
a
a
a
a
a
a
a
Total Acreage:
34.36
ATTACHMENT A -- SITE MAP
Was the facility originally permitted or had a major modification issued after September 1, 2006?
®❑ Yes — Pursuant to 15A NCAC 02T .0105(d), submit a site map pursuant to the requirements in 15A NCAC 02U .0201(d).
These requirements are:
® A scaled map of the site with topographic contour intervals not exceeding 10 feet or 25 percent of total site relief and
showing all facility -related structures and fences within 500 feet of the treatment, storage, and utilization areas.
® Soil mapping units shown on all utilization sites.
® Delineation of the compliance and review boundaries per 15A NCAC 02U .0501(a)(6).
® Setbacks as required by 15A NCAC 02U .0701.
® Site property boundaries within 500 feet of all treatment, storage, and utilization sites.
❑❑ No — Skip Attachment A.
ATTACHMENT B — SIGNATURE AUTHORITY DELEGATION
Does the signature authority in Section I, hem 3 meet the requirements pursuant to 15A NCAC 02T .0106(b)? ❑
®❑ Yes — Skip Attachment B.
❑ No — Submit a delegation letter pursuant to 15A NCAC 02T .0106(c) authorizing the signature authority to sign.
ATTACHMENT C — FLOW REDUCTION
Does the existing permit include an approved flow reduction?
❑❑ Yes - Submit a copy of the flow reduction approval letter, as well as the measured monthly average amount of wastewater
flow contributed per unit for the 12 months prior to permit renewal. If any of these monthly averages are within 20% of the
approved flow reduction value, the Permittee shall provide a reevaluation of the reduced flow value pursuant to the
requirements in 15A NCAC 02T .0114(1).
®❑ No — Skip Attachment C.
ATTACHMENT D — CERTIFICATE OF PUBLIC CONVENIENCE AND NECESSITY
Is the Applicant a Privately -Owned Public Utility? ❑
❑ ❑ Yes — Pursuant to 15A NCAC 02T .0115(a)(1), submit the Certificate of Public Convenience and Necessity from the North
Carolina Utilities Commission demonstrating the Applicant is authorized to hold the utility franchise.
® No — Skip Attachment D.
ATTACHMENT E — OPERATIONAL AGREEMENT
Is the Applicant a Home/Property Owners' Association or Developer of Lots to be Sold? ❑
❑ ❑ Yes (Home/Property Owners' Association) — Pursuant to 15A NCAC 02T .0115(a)(2), submit an executed Operational
Agreement (FORM: HOA). Pursuant to 15A NCAC 02T .0115(c), if the applicant is a legally formed Homeowners' or Property
Owner's Association, submit a copy of the Articles of Incorporation, Declarations, and By-laws.
❑❑ Yes (Developer of Lots to be Sold) — Pursuant to 15A NCAC 02T .0115(a)(2), submit an executed Operational Agreement
(FORM: DEV). Pursuant to 15A NCAC 02T .0115(h), if the applicant is a developer of Tots to be sold, submit a copy of the
Articles of Incorporation, Declarations, and By-laws.
® No — Skip Attachment E.
FORM: RWS-R 02-21
Page 4 of 6

ATTACHMENT F — DEMONSTRATION OF FUTURE WASTEWATER TREATMENT CAPAU I S
Is the applicant a municipality, county, sanitary district, or public utility?
❑ ■ Yes — Proceed to the next question.
► I ❑ No — Skip Attachment F.
Does the hydraulic capacity in Section III, Item 4 exceed 70%?
❑❑ Yes (the hydraulic capacity is greater than 70%, but less than 80%) — Pursuant to 15A NCAC 02T .0118(1), prior to
exceeding 80 percent of the system's permitted hydraulic capacity (based on the average flow during the last calendar year), the
permittee shall submit an engineering evaluation of their future wastewater treatment, utilization, and disposal needs. This
evaluation shall outline plans for meeting future wastewater treatment, utilization, or disposal needs by either expansion of the
existing system, elimination or reduction of extraneous flows, or water conservation and shall include the source of funding for
the improvements. If expansion is not proposed or is proposed for a later date, a justification shall be made that wastewater
treatment needs will be met based on past growth records and future growth projections, and as appropriate, shall include
conservation plans or other measures to achieve waste flow reductions.
❑ ■ Yes (the hydraulic capacity greater than 80%) — Proceed to the next question.
O ❑ No — Skip Attachment F.
If answered Yes above, does the hydraulic capacity in Section III, Item 4 exceed 80%?
❑❑ Yes (the hydraulic capacity is greater than 80%) — Pursuant to 15A NCAC 02T .0118(2), prior to exceeding 90 percent of
the system's permitted hydraulic capacity (based on the average flow during the last calendar year), the permittee shall obtain
all permits needed for the expansion of the wastewater treatment, utilization, or disposal system and, if construction is needed,
submit final plans and specifications for expansion, including a construction schedule. If expansion is not proposed or is
proposed for a later date, a justification shall be made that wastewater treatment needs will be met based on past growth records
and future growth projections, and as appropriate, shall include conservation plans or other specific measures to achieve waste
flow reductions.
■ 0 No — Skip Attachment F.
ATTACHMENT G — EASEMENT, ENCROACHMENT, AND LEASE AGREEMENTS
Does the Permittee own all of the land associated with the wastewater collection, treatment, conveyance, and utilization system?
®❑ Yes — Skip Attachment G.
❑ ❑ No — Pursuant to 15A NCAC 02T .0116(c), provide a copy of all easements, lease agreements, and encroachment
agreements allowing the Permittee to operate and maintain the wastewater collection, treatment, conveyance, and utilization
system on property not owned by the Permittee.
ATTACHMENT H — AFFILIATIONS
Are the Permittcc's affiliations of record correct? Check affiliations.
❑❑ Yes — Skip Attachment H.
®❑ No — Provide the corrected affiliations and their contact information.
ATTACHMENT I — COMPLIANCE SCHEDULES
Does the existing permit include any Compliance Schedules? (See Section I of the most recently issued permit)
®❑ Yes — Submit documentation that the compliance schedules have been met.
❑❑ No — Skip Attachment I.
ATTACHMENT J — CIVIL PENALTIES AND OUTSTANDING VIOLATIONS
Does the Permittee have any existing civil penalties or outstanding violations?
❑ ❑ Yes (civil penalties) — Submit payment for the civil penalty, or proof of remission request.
❑ ❑ Yes (violations) — Submit a copy of your response to the Notice of Violation.
®❑ No — Skip Attachment J.
FORM: RWS-R 02-21
Page 5of6

ATTACHMENT K-- INDUSTRIAL WASTEWATER
Does the wastewater composition in Section III, Item 5 include any industrial wastewater?
❑ ❑ Yes — Proceed to the next question.
®❑ No — Skip Attachment K.
Has the nature of the industrial wastewater changed since the last permit issuance (Le., changes in industrial proccss, introduction
of new materials or chemicals, etc.)?
❑ ❑ Yes — Provide a chemical analysis of the wastewater pursuant to the requirements in 15A NCAC 02U .0201(g). Provide an
overview of the manufacturing process; an inventory of all chemical and biological materials used in the manufacturing
process; and an overview of the cleaning and treatment methodology.
❑ ❑ No — Provide an overview of the manufacturing process; an inventory of all chemical and biological materials used in the
manufacturing process; and an overview of the cleaning and treatment methodology.
ATTACHMENT L — SETBACK WAIVERS
Does the existing permit include setback waivers?
❑❑ Yes — Pursuant to 15A NCAC 02T .0701(a), provide setbacks waivers that have been written, notarized, signed by all
parties involved, and recorded with the county Register of Deeds. Waivers involving the compliance boundary shall be in
accordance with 15A NCAC 02L .0107.
®❑ No — Skip Attachment L.
APPLICANT'S CERTIFICATION
attest that this applicatio
(Signature authority's name as noted in Section I, Item 3)
has been reviewed by me and is accurate and complete to the best of my knowledge. I understand that if all required parts of this
application package are not completed, and that if all required supporting information and attachments are not included, this
application package will be returned as incomplete. I further certify pursuant to I5A NCAC 02T .0120(b), that the applicant, or
any parent, subsidiary, or other affiliate of the applicant has: not been convicted of environmental crimes under, not previously
abandoned a wastewater treatment facility without properly closing the facility; not paid a civil penalty; not been compliant with
any compliance schedule in a permit, settlement agreement, or order; not paid an annual fee.
Note: The Applicant's Certification shall be signed pursuant to 15A NCAC 02T .0106(b). An altemate person may be delegated
as the signing official if a letter is provided pursuant to 15A NCAC 02T .0I06(c). Pursuant to § 143-215.6A and § I43-215.6B,
any person who knowingly makes any false statement, representation, or certification in any application package shall be guilty of a
Class 2 misdemeanor, which may include a fine not to exceed S10,000 as well as civil penalties up to S25,000 per violation.
Signature:
Date: it- '2- D 2
THE COMPLETED APPLICATION AND ATTACHMENTS SHALL BE SUBMITTED AS A SINGLE PDF FILE VIA:
Email:
Non-Discharge.ReportsAncdenr.jov
Lasertiche Upload:
h ttps://edocs.deq.nc.sovfForms/NonDischarge-Bra nch-
Submittal-Form-Vert
FORM: RWS-R 02-2I
Page 6 of 6

Water Pollution Control System Operator Designation Form
«PCSOCC
NCAC I5A 86 .0201
Permittee Owner/Officer Name: Reginald Heinitsh
Mailing Address: 100 Waterfall Circle
City: Lake Toxaway State: NC hip: 28747 - Phone [phone]
Finail address: rheinitsh{aol.com
Signature:
Date: //- 2 o Z/
Facility Name: / e _7 XItmity Permit #: Ida paoa'r3 1
County: /ritIlsy /Va ntQ
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facilit' Type/Grade (CHECK ONLY ONE):
Biological Collection f h)sic,tl.Chemical Surface lrrigaticm Land Application
Operator in Responsible Charge (ORC)
Print Full Name: Geier f]r r,u. A/or10.1 Email: f j i
Certificate Type / Grade / 1\tintber. Si.191.2 L li ork Phone #: $Z -$r_1- + o
Signature:
t � s.r��
certify that 1 agree to my designation as the Operator in Responsible Charge tor tlic fiolny noted I understand and will aht:ie by the rules
and regulations pertaining to the responsibilities of t ll' ORC as set forth 1n 15 1 NC,1L O8G 0204 and tailing to do so can result in Discpltnary
Actions by the 11 ate. Pollution Control System Operators Certification Commission '
Date: S- / - z/
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name_11/006er- Finail•
Certificate T pe / Grade/ umber: S I /oo7 9z. 11 ork Phone #: 'Z B S j -
Signature:
'apt
&tete i'hurr/fi r ofk /HQr/
Date:
• 1 certify that 1 agree to my designation as a Back-up Operator in Responsible Cr;-rge for the tat.di•y noted 1 understand and will abide by the
rules and regulations pertaining to the responsibilities of he BU ORC as set form in I5A NCAC 08G 0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Ccrufication Commission."
,flail, fir or mull the
ariVirral to:
Vail or fax a co/rt' to Me
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center,
Email: certadmint'ia ncdenr.2o%
.Asheville
2090 US I key 70
b%%annanoa 28778
1 ax: 828.249.7043
Phone: [phone]
11 nshington
943 Washington Sy Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Raleigh, NC 27699-1618
Fayette% ills
225 Green St
Sine 714
F tvetteo1lte 2.831A1-5043
Fax : [phone]
Phone: [phone]
Wilmington
127 Cardinai Or
Wilmington 284.+5-2845
Fax: 9I0.350.2004
Phone: [phone]
Mooresville
6101. Center A%e
Suite 301
Moores% i I Ic 28115
Fax : [phone]
Phone: [phone]
Fax: [phone]
11 inston-Snlein
45i1 W. !lanes Mall Rd
R inston-Satetn 27105
Fax; 336.776.9797
Phone: [phone]
Raleigh
380013anett U
Ra sigh 27609
Fax: [phone]
Phone:[phone]
Revises 05-2015