NC0021504_Operator Designation Form_20151001

10l01 l2015 14:18 TOWN OF BISCOE (FAX)910 428 3975 P.002/003
Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Pormittee Owner/Officer Name: 111_r Q4 13ISepe
Mailing Address: PO GO
City: 13 ISCC)L State: Na Zip: 212 - Phone #: 641 Oi 4 28.4 l 12,.
Email address: ���� �"/}ar a if ks . toed i t.��t� 1 xa„ a� ki sc. c.. C»►i
/
Signature: B Dat:,,', %D %=• /c''
Facility Name: -Town CtC' at. .n Permit #: N iC� co Z 1504
SUBMIT A SEPARATE FORM FOR EACII TYPE SYSTEM!
'acilityyyjrie/Gracie:
Biological WWTP
Physical/Chemical
Collection System
Surface Irrigation
Land Application
Operator in Responsible Charge (ORC)
Print Full Name: ' \ MCL5 1Rejd rnc,6k l
Certificate Type / Grade / Number; LOW ti p$ 2 2 Work Phone #; (Ci 10) 428. 4 ! 12
Signature:
Date:
"I certify that I agree to my designation as the Operator in Responsible Charge for the fheility noted, I understand end 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
Aotions_by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: lx-r 1(C U(3 vl rYlc,tr
Certificate Type / Grade / Number: OW I tic} $ 22-5
Signature ; MSG 1/ MCr
Work Phone #: (9l IC)) 42-"a• 4- I l 2.
Date Ma al-
"I certify that I agree to my designation as a Saolc-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 EU ORC as set forth in I5A NCAC 08G.0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certifioation Commission."
Mail, fax or email the
original to:
Mall orfax a copy to the
appropriate Regional Office:
WPCSOCC 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
.r. n
:uYy, i,
i., ?ri (':
Asheville
2090 US Hwy 70
Swannnanoa 28778
Fax:.[phone]
Phone: [phone]
Washington
943 Washington Sq MalI
Washington 27889
Fax: [phone]
!'hone: 252.946.6481
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
I?ex: 910.486.0707.
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
WInstonSalem
585 Waughtown St
Winston-Salem 27107
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
'Fax: [phone]
Phone:[phone]
Revised 02-2013

10/01/2015 14:18 TOWN OF BISCOE (FAX)910 428 3975 P.003/003
Water Pollution. Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name: THY\ 0 C
Mailing Address: PO 13 x 122
City: 16 1
State: NC Zip: 21 2_,C53-
Phone #: (i iO) 42.e - 4 112_.
Email address:
Signature: Date; /0 " /
Facility Name: -Old h O cP. Permit #: W O.0 SO° 1 Col
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEMS
Facility Type/Grade:
Biological WWI
Physical/Chemical
Collection System X - l 1
Surface Irrigation
Land Application
Operator in Responsible Charge (ORC)
Print Pull Name: Ge-Orc3e., m1ei. 'Turn or-
Certificate Type / Grade / Number: Cat lec.-h DY-, SACrY\ Work Phone #: ('1tO 1 42-e • 4 l 12.,.
11 ..
qq 1.11241-
Signature: , 7zf:2h L
Datei /6-/-/6-
"I certify that I agree to my designation as the Operator 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 Commission:'
Back -Up Operator in Responsible Charge (BU ORC)
Print pull Name: -1T-1 ornas 2'-4d me t5•! .r'
Certificate Type / Grade / Number: IOWA., J00 ! i' 6 7 Work Phone #: (9(0) 42$ • -41.II
Signature:� —
Date: iQ / /5-
"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 set fbrth in 15A NCAC 08e .0205 and fhiting to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email the
original to:
Mail or fax a copy to the
appropriate Regional Office;
WPCSOCC,_1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: 919.807,6492
Asheville
2090118 Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
'Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: /04.663.1699
Winston-Salem
585 Waughtown St
Winston-Salem 27107
Fax: 336,771.4631
Phonci 336,771,5000
Raleigh
3800 Barrttt Dr
Raleigh 27609
iFax: 9195iL4718
Phone:919,791.4200
Revised 02-2013

10/0112015 14:17 TOWN OF BISCOE
(FAX)910 428 3975 P.0011003
Town of 13fscoe
110 West Main Sleet
PO Box 1228
Biscoe% NC; 27209
Phone : [phone]
Fax : [phone]
FAX
Page 1 of 3
ATTENTION:../ a r e>t
Company: _ � ; ; a rL o 14' , r R eScac2
Date: 10 - 1—
Fax: 9`/a'- '(p 1? c3'7
From: cio„
Comments:
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PLEASE CONTACT US IF THIS FAX IS DELIVERED TO THE WRONG PART