NC0050661_Delegated Authority_20211018

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Water Pollution Control System Operator Designation Form
WFCSOCC
NCAC 1SA 8G .0201
Perinittee Owner/Officer Name: nevi viis .Setyt 4 erge n ^ Mu.v o r-
Mailing Address; Po io2C t aS
City: Ma.C.Clesc;eltvl State: NZip; 278(4- Phone#: ZS2 $2.7-b1a23
Email address; [.,lout,UG 0 a► evvllogr9 vna: I . COm _ Signature: �� Date: /9 ` o7 rP —440 0V
Facility Name: Taw to elc
County: Eooigtcaiink,er
Permit #: /VL4:10.50(ate
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
Collection Physical/Chemical Surface Irrigation Land Application
Operator In Responsible Charge (ORC)
Print Full Name: Email:
Certificate Type / Grade / Number: Work Phone #:
Signature: Date:
"I certify that 1 agree to my designation as the Operator in Responsible Charge for the facility notes. I understand and will abide by the rules
and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 080 .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: [.A r 10 let era 5 Email:, CSr(ug 1,411 t i fir► f' 19 i (. CG,) 6.6 Coo.%
Certificate Type / Grade / Number: _ of C'l Qg - 9 Work Phone #: 252 5 y y " 3 7 3 3
Signature: i Date: 1 -27 - I
"I 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 I3U ORC as set forth in ISA NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mall, fax or email the
privinal to:
Mall or fax a onto the
appropriate Regional Office:
WPCSOCC 1618 Maid Service Center, Raleigh, NC 27699-1618 Fax: [phone]
•01,..
s,•t.
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: 252,946,6481
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: 910.350,2004
Phone: [phone]
Mooresville
61 C E Center Ave
Suite 301
Mooresville 28115
Fab: 704.663.6040
Phone: [phone]
Winston-Salem
45C W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: 919.571,4718
Phone:919.791,4200
Revised 05-2015