NC0034452_ORC Designation Form_20240812

Date; L— I'l 2v"Lf
Work Phone: [phone]
Certificate 0: 1015439
Signature: - rJ _ Effective Date: V �'%mr
I certify that I agree to my designo as the Operator in Responsible Charge far the facility noted. I understand and wdl abide by the rules and regulations perroming
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 V/PCSOCC"
Backup ORC
Full Name: Donte Lamont Campbell Work Phone: [phone]
Certificate Type: WW El Certificate Grade: IV 0 Certificate #: 1014158
Signature: ✓7�� ( Effective Date:�2 f ZpZy
") certify that I agree tom designation as the Opera r in Responsible Charge for the facility noted. l understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORC as set forth in 15A NCAC 08G .0104 and folling to do so can result in Discrphnay Actions by the WPCSOCC'
Full Name-.
Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 1SA 8G .0201
TAR to Navigate Form
Facility Name: Willow Creek
Facility Type/Classification; Select
Permittee Owner/Officer Name:
Email Address:
Permittee
ORC
Full Name: Justin Allen Stein
Permit n NCO034452
Facility Grade: Select SUBMITA SEPARATE FORM FOR EACH CLASSIFICATION
Email Address: [e-mail]
Carolina/ " +�,r ., - A in-wi
Certificate Type: W►N 0 Certificate Grade: II 0
Backup ORC
[phone]
Certificate Typc: WW 0 Certificate Grade: II 0 Certificate q: 11008
Samuel E Pegram
Work Phone
Signature: c. &�_r. Effective Date: b�J"i certify that 1 agree to my designation as the OperatoesponsiNe, Charge for the facility noted. I understand and wilt abide by the rules ind regulations
perrolning to the responsibilities of the ORC as set forth in 15A NG4C 08G .0204 and falling to do so ran result in Drscipllnory Actions by the WPCSOCC'
Email this form to: [e-mail]
AND
Send to your DEQ Regional office (send to your contact or find emails here: www.deq.nc.gov/about/contact/regional-offices
or fax using this drop down list: Choose DVVR Regional Office that has coverage of this facility.
Use the 2nd page only if you need to list additional Backups.
'� "

Facility Name: Willow Creek Permit #: NCO034452
Backup ORC
Full Name: Peter Ray Dealing Work Phone: [phone]
Certificate Type: WW [- Certificate Grade: II [} Certificate #: 997449
Signature: Effective pate: �]� • b2� r �j_�.�
'I certify that I agree to my designaton the Operator In Respon Ic Charge for the focr'11ty noted. l understand and will abide by the rules and regulations pertaining
to the responsibilities of the Mcas set forth in 15A NCAC 08G 204 and falling to do so con result in Disciphnory Actions by the VIKSOCC"
Backup ORC
Full Name: Richard E McFadden
Work Phone: (336� 362-4150
Certificate Type: WW El Certificate Grade: It El
Certificate #:
Effective Date:"�''z�
Signature:
i certify that i agree to my designation as the Operator in Responsible Charge for the focxty noted.
I understand and will abide by the rules and regularions perroWng
to the responsibilities of the ORC os set forth in 15A NC4C 08G .0204 and falling to do so can result in DisciplinaryActions by the VJPCSOCC'
Backup ORC
Full Name:
Work Phone:
Certificate Type: Select Certificate Grade: Select
Certificate #:
Effective Date:
Signature:
I certify that t agree to my designation as the Operator in Responsible Charge for the facility noted.
1 understand and wilt 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 WPCSOCC'
Backup ORC
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Signature: Effective Date:
I certify that 1 agree to my designalion as the Operator in Responsible Charge for the facility noted. I understand and -MY abide by the rules and regulations pertaining
to the responsibilities of the ORC asset forth in 15A NCAC08G,0204 and failing to do so can result in Disciplinary Acrlans by the WPCSOCC'
Revised 02e2024

Wager Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
TAB to Navigate Form
Facility Name: Spring Creek Permit )t NCO083941
Facility Type/Classification. WW 0 Facility Grade: II F-1 SUBMITA SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: A uq a Nord Carolina
Email Address: _d61tf-WOAWarvKJ?4 f&A
Permittee Signatuf e: ��% Date: - - 9,0`2Y
ORC
Full Name; Justin Allen Stein Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: WW El Certificate Grade; II El Certificate $I:
1015439
Signature: Effective Date: b/ 9-
'I certify that I agree to my deli lion as the Cperator in Responsible Charge for the focility noted. I understand and will abide by the rules and regulotions pertaining
to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to an so can result in OiscipiinaryActions by the WPCSOCC"
Full Name:
Donte Lamont Campbell
Certificate Type: WW 0
Backup ORC
Certificate Grade: IV E
Work Phone: [phone]
Certificate 4: 1014158
Signature; & / .p111i- Z___: v� Effective Date: �jl2/2,?Y
"I certify that I agree to my esignatonntas the Operator rt Responsible Charge for the focihty noted, i understand and will abide by the rules and regulahorrs pertaining
to the responsibilities of the ORC os set forth in 1SA NCAC 08G 0204 and falling to do so can result in Disciplinary Actions by the W➢CSOCC"
Backup ORC
Full Name:
Samuel E Pegram Work Phone: [phone]
Certificate Type: W W 0 Certificate Grade: II 0 Certificate ft: 11008
Signature: Eff47
ective Date: r7
'I certify that I agree to my destgnorion as the Operator in Re onsibie Charge for the facility noted I understand and will abide by the rules and regulations
pertaining to the responsibilities of the ORCos set forth in 15A NCAC 086.0Z04 and falling to do so con result in DisciptinaryActions by the W➢CSOCC-
Email this form to: [e-mail],gov
AND
Send to your DEQ Regional Office (send to your contact or find emails here: www,deq.nc,gov/about/contact/regional-offices
or fax using this drop down list: Choose DWR Regional Office that has coverage of this facility.
Use the Znd page only if you need to list additional Backups.
Revised 0212024

Facility Name: Spring Creek Permit #:
NCO083941
Backup ORC
Full Name: Peter Ray Dealing Work Phone: [phone]
Certificate Type: WW 0 Certificate Grade: II 0 Certificate #: 997449
{
Signature: Effective Date: L� -p 2 - 26zY
"icertlfy that! ogres to my designation as he Operator in Responsible Charge for the facility noted, 1 understand and will abide by the runes and regulotloys pertaining
to the responoblities of the ORCos set forth in 25A NC4C08G .0204 and failing to do so can result In OrsclplinaryActions by the WPCSOCC'
Backup ORC
Full Name: Richard E McFadden
Certificate Type: WW 0 Certificate Grade: Il 0
Work Phone:_ [phone]
Certificate #:
Signature: - -- Effective Date: 1%�2
'I certify that I agree to my designation as the Operator in Responsible Charge for the focllity noted. I understand and will abide by the rules and regulada: rs pertalning
to the responsibilities of the ORC as set faith in ]5A NCAC 08G.0104 and falling to do so can result In DliclplinoryActions by the WPCSOCC'
Backup ORC
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Signature: Effective Date:
"I certify that 1 agree to my designation as the Operatorin Responsible Charge for the facility noted, t understond and wr71 abide by the rotes and regulations pertolning
to the responsibilities of the ORCos set forth in i5A NCAC 0BG.0204 and falling to do so can result in DlsciplinaryActions by the WPCSOCC'
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 the Operator in Responsible Charge for the facility noted. t understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORCos set forth In ISA NCAC 08G.0204 and failing to do so can result In Disciplinary Actions by the VVPOOCC"
Revised 0212024