WQ0005150_ORC Designation Form_16102023

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
TAB to Navigate Form
Facility Name: North End Elementary Permit # W00005150
Facility Type: Select Facility Grade: Select SUBMITA SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Person County Schools / Rodney Peterson
Email Address:
n.k12.nc.us
Permittee Signature: !J
ORC
Operator In Responsible Grorge
Full Name: Steven Lawrence Gentry
Date: I Q U Q f 2,3
Work Phone: [phone]
Email Address: gentrys@u personAl2.nc.us
Certificate Type: Si 0 Certificate Grade: N/A 0 Certificate #: 1014049
Signature: Effective Date: % z - / - Z 7
"I certify that I agree to my designation as the or 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."
Backup ORC
Full Name: Paul Jason Phillips _ Work Phone: [phone]
Certificate Type: Sl 0 Certificate Grade: N/A 0 Certificate #: 986029
Signature: Effective Date: 2 Z 3
"1 certify that agree to my designation ps 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 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
Full Name
Certificate Type. Select Certificate Grade: Select
Signature
Work Phone:
Certificate #:
Effective Date:
"I certify that I 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 15A NCAC 08G .0204 and failing to do
so can 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 1 FAX: [phone] [e-mail]
Mail or fax a COPY to: Choose DWR Regional Office that has coverage of this facility.
Revised 812023