WQ0004166_ORC Designation Form_20221019

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
'JCAC 15A 5G 020.
Permittee Owner/Officer Name:
Email Address:
Permittee Signature:
Facility Name:
Press TAB !venter ,nfor;o"
TowJFegor/"
Tm Churc.l
.e wnS E c er uryil nk. feet
...,eVerson. WWTP
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM:
Date
Permit u
Faci'tity Type
S/q/zQzl
WQ0004166 PB
NnOZ17O
Select REAP
Facility Grade. Select
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name:
Certificate Type: Select ' RI A P 1s..1 Certificate Grade:
1
Email Address je,ii-cwns e Certi-ury)Ink.
Signature:
fi.„„elloAtL
Select
Work Phone'
Certificate 4.
Effective Date
"I certify that 1 agree to my designation, as the Operator in Responsible Charge for the facility noted
33(0)2ffc-21(05
{y73(0
8/4L24,z1
1 undenrand and
;V.ir ndrdt by :ht•
rules nod regulations pertaining to rh•• responsibilities of the ORC as set forth ,n !SA +JCAC 08G 020.1 ant. Iaiuri7 !o do so CCP'
DiSciplinary Actions by the Water Pollution Control System Operators Cerr frcotron Comm'",tin
Print Full Name.
_ Dv Or
Certificate Type. Select RLRP
Email Address:
Signature:
Certificate Grade: Select
1 •/FJne
Work Pbon'°
Certificate ::
3,(.c24U 3558
/ 00 3070
Effective Date: 0,f3/f2/L(
'7 certify that 1 ogre my designation a5 a Back -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 r'CAC 08G 020,1 and fading t❑ do so c u•, •t•sul• •n
Disciplinary actions by the Water Pollution Control System Operators Certification Comrn;s sion
Mai!, 'a.% or email
ORIGINAL to:
WPCSOCC. 1618 Mail Service Center, Raieigh, NC 27699 1618
Email: ceitadmin!tancdenr.gov Fax: [phone]
Mail or Pax a COPY to: Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: 828•296 4500
Washington
943 asrington Sq. Mail
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St . Suite 714
avetteville. NC 28101 504
Fax: 910 •:8b 0707
Phone:91C .33 3300
Wilmington
12Cardinal Ur
Wilmington, NC 28405-2845
Fax: 91C-350-2004
Phone:[phone]
Mooresville
610 E Cer r Ave . S..•:e 301
Mori. •,viiie. NC 2811
Fax: 701 tin; 60. 0
Phone: '0.: 663 1e99
Winston-Salem
a5 $v 1,1,11 Rd
Winston-Salem, NC 27105
Fax: [phone] Phone:
336 776-9800
Raleigh
3R00 Barr is 0-
Ra•F g", NC 2 '• (Y;
Fax: ~13 ',71 i18
Phone: [phone]
'4e.•sea 5,7'_',