HomeMy WebLinkAboutNC0021504_Operator Designation Form_20100225General Information:
Petnlittee Owner/Officer Name: TOWN OF BISCOE (JANES E. BLAKE, MAYOR
Water Pollution Control System Designation Form
WPCSocc
NCAC I5A:05C .0201 ENR—FRO
1AR 0 142010
Min
Mailing Address: PO BOX 1228
City: BISCOE
• Telephone Number:
Signatur
State: NC
910 ) 428-4112
zip: 27209
Date: 02-25-2010
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Facility information:
Facility: TOWN OF . BISCOE
Permit Number: WQCS 00167
County: MONTGOMERY
! SUBMIT A SEPARAlh FORM FOR EACH TYPE OF SYSTEM !
Mark (X) Type of Facility Class (1 — 4) Class
Wastewater Plant Spray Irrigation N/A
Physical/Chemical Land Application N/A
Collection System X 2 Subsurface NIA
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Operator in Responsible Charge:
Print Name: SAMMY R. STEWART
Certificate Type and Grade: CS-2
Work Telephone: (i1(1) 428-4112
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Social Security # : 244-25-4578
Certificate #: 987467
Signature:_
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Pack -Up Operator in Responsible Charge:
Print 1•Name: DAMES D. ASBILL Social Security # : 288-68-0648
Certificate Type and Grade: CS-1
Wort: Telephone: 9( 10 ) 428-4112
Mail or Fax to:
Signature:
WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699.1618
k a : 9191731 i38
Certificate #: 15959
•
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ReSiiea 1612.00