NC0090166_ORC Designation Form_20240208

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
NCAC 15A 8G .0201
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Facility Name: PRESS CLUB CLEANERS BROWNFIELDS PROPERTY Permit #
NCO090166
Facility Type: Select Facility Grade: Select SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: CH MF BTH III / Charlotte LoSo LLC
[e-mail]
Email Address:
Permittee Signature: Date: ?Jw4
ORC
Operator in Responsible Charge
Full Name: Matthew James Westendorf Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: PC Certificate Grade: I Certificate #: 987697
Effective Date: 2-07-2024
Signature:
"I certify that 1 ra�gree 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 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: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Signature: Effective Date:
"I certify that I 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 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: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Signature: Effective Date:
certify that I 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 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: IChoose DWR Regional Office that has coverage of this facility.
Revised 312019

Facility Name: PRESS CLUB CLEANERS BROWNFIELDS PROPERTY Permit M
Full Name:
Certificate Type: Select
Signature:
Backup ORC
Certificate Grade: Select
Page 2
NCO090166
Work Phone:
Certificate M
Effective Date:
"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 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:
Work Phone:
Certificate Type:
Select Certificate Grade: Select Certificate #:
Effective Date:
Signature:
"I certify that i 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 ORC as set forth in 15A NCAC 08G .0204 and foiling to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Backup ORC
Full Name:
Work Phone:
Certificate Type:
Select Certificate Grade: Select Certificate #:
Effective Date:
Signature:
"1 certify that I 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 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:
Work Phone:
Certificate Type:
Select Certificate Grade: Select Certificate #:
Signature:
Effective Date:
"I certify that I 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 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."