NC0082716_ORC Designation Form_20210713

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
NCAC 15A 8G .0201
rAft to Novlgate Fprm
Facility Name., WOLF LAURIL WWTP Perrhit* NC0082716
facility Type; W,
Permittee Owrfer/Offlcer Name.
Permittee Signature:
':A/,c.';ter Ouallty Regi a
Asheville Regional Office `
Date:
Full Name: PM �s JP\M S Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: Ww Certificate Grade: It ® Certificate #: C Ll b
Signature: Effective Date: '1 " ( — �_1
"I cert;f hat l 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 asset forth in 15A NCAC 08G .0204 and
failing to do so can result in DisciplinaryActions by the Water Pollution Control System Operators Certification Commission."
Full Name: _3yAN Mjn� 316�mf_5 Work Phone: [phone]
Certificate Type: VVVV Certificate Grade: I I 1 Certificate #:_Z� {
Signature: Effective Date: '� _ I -7-1
"I certehLt l agree tomy designati a Back-up Operator in Responsible Chargefor thefacility noted. 1 understand and will
abideules 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."
Full Name: �N�� �f'�M�S
Work Phone: [phone]
Certificate Type: VW/ Certificate Grade: 11
Certificate #:
Signature:
Effective Date:_`1w
"I certify that/ agree to my designation as a Back-up Operator In Responsible Charge for the facility noted l and 1 stand and will
abide by the rules and regulations pertaining to the responsibilities of the ORC as set forth in ISA NCAC 08G .0204 and failina to do
cn rnn rondo;.,
Certification Commission."
Mail, fax or email ORIGINAL to: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 1 FAX: 919-71S-2726 I [e-mail]
Mail or fax a COPY to: Asheville-2090 US Hwy 70, Asheville, NC 28778 1 FAX: [phone] PH: 828-296-4500
Revised 312019

Page 2
Facility Name: V (U% L' j _Clu W N—n> Permit #: NGo )-LI-4 k(o
Full Name: ,NM'S -S1�/� �— Work Phone: 8j2,�}9
Certificate Type: WW Certificate Grade: I Certificate #: Iota 7.6-2_,
Signature: &04-Effective Date: ]_ � _7
"I certify that I agre 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 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."
Full Name:
Work Phone:
Certificate Type: WW Certificate Grade: Select 2 Certificate #:
Signature: Effective Date:
"I certify that/ agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. l understand and will
abide by the rules and regulations pertaining to the responsibilities of the ORC as set forth in ZSA NCAC 08G .0204 and failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Full Name:
Work Phone:
Certificate Type: WW Certificate Grade: Select
�Certificate #:
Signature: Effective Date:
l certify that l agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. / understand and wili
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."
Full Name:
Work Phone:
Certificate Type: WW Certificate Grade: II
Certificate #:
Signature
Effective Date:
"I certify that/ 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 ORC as set forth In 1SA NCAC 08G .0204 and failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
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