NC0024571_Operator Designation Form_20190701

E.B'/27/ U 1'9/'NED 02:44 PM
FAX No, F, 002
Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 86.0201
Perrnittee Owner/Officer Name: ? Ob02- 4 r v S-6-) y rPtAi LLthl i te.c.:7-cdt
Mailing; ,Address: C �-� d 4 Lie Y b4 r r' C Oft. 1 Mg Le w-.i r ,. b� C 2.8 3S'7
3s ~; r
City: Lu ,Aber-r State: Pl C- Zip: 283b'` - Phone #: 10- Co % (-a--i sue"
Ernail address:
iL3 G-1-r (S G'feLuhn%P!"Ivp•Y)C. (�
Signature: � P /
Date: .7 ` Z 7� I `2/
Facility Name: 0,14y (7 + L►) or, b °r-40,1 S �tt _( iZ e tit i Permit #: Ncoaa4s71
C<trinty: Igo bes Y-1
Biological)
SUBIVfT A SEPARATE FORM FOR EACH TYPE SYSTEM
acility Type/Grade (C ECI( ONLY ONE):
Collection Physical/Chemical Surface Irrigation , Land Application
Operator in Responsible Charge (ORC)
Print Full Name: rJ(�nn a r . ' M 8 f S Email: aW owk-efts Q rA6er-AAA -0 nc. u,.S
Work Phoilert:q/0-Ds-$" o 7
Certificate Type / Grade / Number: l,17 (n.) S )1 y-
Signature:
"1 certify that I ag4Ee 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 as set forth in 15ANCAC 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. Naive: \le r l�)/ r'o,� \\Fxr'+ ig.r' ' Email: N t4ww Pert c f ,1_vMb�r��. ti't , . its
Certificate Type / Oracle / Number: Vd vJ 1 'b> (GS')OY Work Phone #: C i o . [>a 1 • }S
Signature:
•9741
"I certify that 1 agree to esigrratioo 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 080.02.05 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission:"
Date: ; a`' `v\
Mail, fax or email the
original to:
Midi or fax a cor v to the
appropriate Regional Office:
W:PCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
Email: certadmiaiaucdenr.aov
Asheville
2090115 Hwy 70
Swannanoa 28778
Fax; 828.299.7043
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone].
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 B Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
:Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Pirrone: 336.776.9800
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 05.2016

27/2019/WED 02:44 PM
FAX No, P, 001
' '7,77Pit7;;;•;..,
UMBERTO
ENVIRONMENTAL UTILITIES LABORATORY
PO Box 1388
700 Lafayette Street
Lumberton, NC 28359
Phone: [phone]
Fax: [phone]
FAX COVER SHEET
DATE: h
# of Pages (including Cover)
To: IV .dD g A.I
Whaigt-iiaile
ea, 0707 AO
FROM: .7-am,,
7r„
1;„
e4t/ 0
Comments:
pa-40,40 g• e , rl AR ev,
Chariseld cA4 a elcied Ad.61MJii 3kirp dge

19,1ED '11:16 AM
FAX No, P, 001;' 111
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Permittee Owner/officer Name:
Email Address:
Permittee Signature:
Press TAB Ito enter information
1 rs
Ci. ivWDQ.,, , n „ �5
Facility Name: City of Lumberton WWTP
Date:
Permit # NC0024571
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: WW
Facility Grade: IV
ORC - OPERATOR iN RESPONSIBLE CHARGE
Print Full Name: Henry Byron HaSper Jr.
Certificate Type: WW Certificate Grade: iV
Email Address: [e-mail]
Signature:
Work Phone: [phone]
Certificate #: 1008147
1
Effective Date: -1 -. \-
"! certify that 1 agree to r roc signation if Operator in Responsible Charge for the facility noted. 1 understand and will abide by the
rules and regulations pertaining to the re, ponsibilities 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."
BACKUP ORC
Print Full Name:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select
Work Phone:
Certificate #: •
Effective Date:
"1 certify that I agree to mydesignation 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 con result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission." •
Mail, fax or email
ORIGINAL to:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Email: certadrnln@ncdenr,gov Fax: [phone]
Mail or Fax a COPY to: Asheville Fayetteville Mooresville Raleigh
2090 US Hwy 70 225 Gr'een'St., Suite 714 610 E. Center Ave., Suite 301 3800 Barrett Dr.
Swannanoa, NC 28778 Fayetteville, NC 288301-5043 Mooresville, NC 28115 Raleigh; NC 27609
Fax: [phone] Fax:[phone] Fax:[phone] Fax: [phone]
. Phone: [phone] Phone: [phone] Phone: [phone] Phone: [phone]
Washington Wilmington Winston-Salem
943 Washington Sq. Mall 127 Cardinal Dr. 45 W. Hanes Mill Rd.
Washington, NC 27889 Wilmington, NC 28405-2845 Winston-Salem, NC 27105
Fax: [phone] Fax; 910-350-2004 Fax: [phone] Phone:
Phone: [phone] Phone: [phone]
Revised 6/2019