NC0043320_Operator Designation Form_20120926

0S 28/2012 081:53 FAX [phone]
ITG
Water Pollution Control System Operator Designation Form
wpcsocc
NCAC 15A SC ,0201
Permittee Owner/Officer Name:
Burlington Industries, LLC / Doug Carter
_IFRC
SEP '16 2012
owe
Mailing Address: P.O. Box 250 740 Old Cheraw Highway
City: Cordova
State: NC Zip: 28330
Email address: doug.f rterga itg-global.com
Signature:
dat
Facility Name; Burlington Industries, LLC
Phone #: falQ 1 997-1297
Date: 09/26/2012
Permit #: NC0043320
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade:
Biological WWTP
Physical/Chemical
Collection System
Grade 3
Surface Irrigation
Land Application
Operator in Responsible Charge (ORC)
Print Full Name: Hiram Terry Davidson, Jr.
Certificate Type / Grade / Number: WW-3 / 997816 Work Phone #: (910 ) 997-1207
Signature: , / 7' Date: 09/26/2012
'd,ccrti'fy that I agree t0 my desiaa'netion as the Operator in Responsible Charge for the facility noted. I understand and will abide by thc 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 (E'U ORC)
Print Full Name: Peter Jan Borton
Certificate Type / Grade / Number: WW-2 / 997648
1
Work Pbozie #: (910 ) 997-1207
'Signature: Date: 09/26/2012
•
r`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 thc
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC OSG .0205 and failing to do so can result in
Diseiptinaiy Actions by the Water Pollution Control System Operators Certification Cotmnission."
Mail or fax the original for
•
Mail or fax a copy to the
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Washington
043 Washington Sq Mall
Washington 27889
Pax: 252.946.9215
Fayetteville
225 Grccn St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Mooresville
610 E Centel Ave
Suite 301
Mooresville .181.15
Fax: 704.66:t.6040
Winston-Salem
585 Waughu•wn St
Winston -Salim 27107
Fax: 336.77I.4631
Raleigh
3800 Barrett Or
Raleigh 27609
Fax: [phone]
Revised 6-2012