NC0047562_Operator Designation Form_20170719

Jul 20 17 07:27a Fax
910 582-6074 p.1
201 West Main Street
Post Office Box 1229
Hamlet, North Carolina 28345
July 19, 2017
WPCSOCC '
1618 Mail Service Center
Raleigh, NC 28699-1618
Re: Changes to Operator Designation Form
City of Hamlet - Permit No. NC0047562
Dear Sir or Madam,
Phone [phone]
Fax [phone]
www.hamletnc.us
The City of Hamlet in Richmond County, North Carolina, as of today's date, July 19, 2017, Jonathan
D. Blanton will be the Permittee Owner of the City of Hamlet's Wastewater Treatment Plant to the
above referenced permit number. Also, Mr. Kevin Bowman will be added as back-up ORC, Grade
WW2, Certification No. 1004846 to the same permit number listed.
Sincerely
Earl G. Dunn, ORC
City of Hamlet Wastewater Treatment Plant

Jul 20 17 07:25a
Fax
910 582-6074 p.1
Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permutes Owner/Officer Name: 01 of I/oinlei1Jn1ilhzj D. 8)wkn
Mailing Address: P 0. BOX I 1
City: It? ?IeF
Email address: ,rl Q /.0
Signature:
Facility Name:
Zip: Orb J'1.:1 Phone #: (71 o) 522 -.Us")
fri
Date: o -1! 0)
ei i or llam/ e 1 t! W T! Permit,, J Y e O Dq 15l'!OL
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade:
Biological WWTP -j Surface Irrigation
Physical/Chemical Land Application
Collection System
Operator in Responsible Charge (ORC)
Print Full Name: 6tf' (-4 D
Certificate Type / Grade /Number: ca.j 1.J 3 ,g 600
Signature: )
Work Phone #: (qI•af? 7
Date: 1 / l () ! f
"I certify thatl agree to my designation as the Operatorin Responsible Charge for -the facility noted. Iunderstand 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 Full Name: ��/}RR Ct. L LAlarre I_A t,) eiQ y
Certificate Type((jj/ Grade / Number:UtI1A)3 /0 a y 81 S Work Phone #: C9/)) 58�- — 4'D'ILjf
Signature: �/ctnvite/ 4447).lP-A,Awier
"I certify that I agree to my designation as a Back-up Oper r 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 forth in 15A NCAC 08G _0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Date: 7-/7—/
Mail or fax the original to:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
Mail or fax a copy to the Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
appropriate Regional Office:
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax; 910350.2004
Mooresville
610E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Winston-Salem
585 Waughtown St
Winston-Salem 27107
Fax: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Revised 6-2012

Jul 20 17 07:25a Jax
910 582-6074 p.2
Facility Name: a Z i }( G / ii1.4G 7 4,y((/fp
Permit #: /1-/G2- DO 44 i5-K2......
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: `l 6 L1(' A--- 4, (G 414'
Certificate Type / Grade / Number: wiLILL fee rf
Signature:
Work Phone #: (q/o)
Date:
"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 forth in 15A NCAC 08G .0205 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 Full Name: gbr<IG (,o c r
Certificate Typel Grade /Number: &% .1 -2)-2_9 Y. Work Phone #: (Q(0) �j ICI 7
Signature:
Date: I /l /7 %7
"I certify tbat I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and ‘vi1l abide by the
rules and regulations pertaining to the responsibilities of the DU ORC as set forth in 15A NCAC 08G .0205 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 Full Name:
Certificate Type / Grade / Number- Work Phone #: ( )
Signature: Date:
"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 forth in 15A NCAC 0SG .0205 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 Full Name:
Certificate Type / Grade / Number: Work Phone #: ( )
Signature: Date:
"I certify that I agree to niy 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 forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 6-2012