WQCS00069_Designation Form_20210920

Sep. 17, 2021 10:35AM Town Of Farmv i 1 l e No. 5999 P. 1/2
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM eglECTOCCENR/DWR
NCAC 15A 86.0201
Permittee Owner/Officer Name;
Email Address:
Permittee Signature:
Press TAB to enter information
David Hodgkins
[e-mail]
Facility Name: Town of Farmville
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: CS -II
SEP 2 0 2021
Water Quality
Regional Operations Section
Washington Regional Office
Date: Ali//r4
Permit # WQCS00069
•ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Brian Eugene Shackelford
Certificate Type: CS 0 Certificate Grade: 11 B Certificate #: 1001392
[e-mail]
252-341-8221
Email Address:
Signature:
Work Phone:
Effective Date:
"1 certify that 1 agree to my designation as the Operator in Responsible.Charge for the facility noted, 1 understand and will abide by the
rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 086 .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Martin Alexander Harrell
Certificate Type: CS 0 Certificate Grade: 1 0 Certlfitate #:
Email Address: [e-mail]
Signature:
Work Phone: [phone] •
1001326
Effective Date: /17�y,�,►._�
noted. ! un erstand and will a
Responsible Charge or the facility
"1 certify that 1 agree to my designation as a Back-up operator in g f f y bide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth In 15A NCAC a8G .0204 and failing to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
ORIGINAL to:
Mail or Fax a COPY to:
Email: [e-mail] Fax; 919-715-2726
Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax; 828-299-7043
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax;910-486-0707
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone; 704-663-1699
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax; 336-776-9797 Phone:
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax; 919-571-4718
Phone: [phone]
Revised 11/2020

Sep,17,2021 10:35AM Town Of Farmville
No.5999 P. 2/2
Signature:
Facility Name: Town of Farmville
Page 2
Permit #: WQCS00069
•
Print Full Name: Jonathan Louts Cowan
CKUP ORC.
work Phone:[phone]
Certificate Type: CS CI Certificate Grade: la Certificate #:996904
Email Address: [e-mail]
bkatAC
Effective Date:
�1il12021
"1 certify that ! agree to my designation as a Back-up Operator in Responsible Charge far the facility noted. 1 understand and will abide by
the rules and resul❑tions pertaining to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and falling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Print Full Name:
BACI
Certificate Type: Select certificate Grade: Select
Email Address:
Signature:
Work Phone:
Certificate #:
Effective Date:
"1 certify that 1 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 15A NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission,"
Print Full Name:
Certificate Type: Select
. Email Address:
Certificate Grade: Select
Work Phone:
Certificate #:
Signature:
"! certify that i agree to my designation US a Bock -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."
Effective Date:
Print Full Name:
BACKUP
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select
Work Phone:
Certificate #:
Effective Date:
"l certify that 1 agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. 1 understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in I5A NCAC 08G .0204 and failing to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission,"
Rovlsed 11/2020