NC0086592_Operator Designator Form_20220324

Water Pollution Control System Opera or Designation�
wPCSQCC
NCAC f5A RG .t 2Hl.
Perrnittee n r/Of er 'ante:
olina
ater Service of NC
piyfIDINGDEQ/DINFI
MAR 't, 4 2022
W©ROS
Mailing Address: 49 4 Parkway Plaza Blvd, suite 375
City: Charlotte
State: NC dip:.
28217
Email address; tony.lkonsulacaralinawa se ieen .e
ignature. Tony Konsul
MOORE
4 1 525-7990
AL OFFICE
Facility Nal<nne: The Pc inr Well 1 Permit #: NC0086592
sunmiT A SE A TE FORM FOR EACH `l` P`E SYSTEM!
Faeility TvpGrade:
Biological WWTP
Physical/Chemical
Collection System
Operator in Responsible Charge (ORC)
Print Full Name: Mark R. Haver
-
Surface Irrigation
Land Application
Certificate Type I Grade I Number: PC 1 994053
Work Phone #: [phone]
Signature: f Date: 2-- - r 2'
"1 certify that l: agree to my desi tiara a rite Operator in Responsibte Charge firr rife eitity noted. t etude€stand and Will abide by the odes
and regulations pertaining for the res2sancil ib!ies oldie ORC as set firth in 1SA NCAC NG .0204 and failing to do so can result in Disciplinary
Actions by the hater Pollution Control System Operators Certification Commission."
Bark -Up Operator in Responsible Charge (BU ORC)
Print Full Name: T©n Konsul
Certificate Type o Grad d Number: PC - l
985369
\' "Fork Phone #: ( 7041 576-I685
Sigtnature
&mom S,OcIN
Date:
l certify that t agree to my deaignati€trt as a Back-up Operator in Res/Ion sitrle Charge for tlr facility noted. 1 understand and will abide- by the
rules and regulations pertaining to the responsibilities of the r11' ORC as set forth in 15A NCAC 08G .t1205 and Failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Cortunisnon."
Mail; fax or email the 'PC €;~CC, 1618 Mail Service Center, Rateighr NC 27699-1618 Fax: [phone]
arigirraf to. . ov
Hail ar fax a copy ra
apprapria � i€ ffftl
Asheville
2090 US tiwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington.
943 Washington Sq troll
Washington 27339'
Fax: 252.946.921
Phone: [phone]
Fayetrwille
'25 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Mimi/Mon 23405-2845
Fax: [phone]
Phone: [phone]
Mooresti4i
610 E Celt [c€ Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
%%instant-Saleut
585 l4aughtown St
Winston-Salem 27107
Fax: [phone]
Pho tit: 336.771.5000
Raleigh:
38800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised t 2-2013