NC0067326_ORC Designation Form_20240815

Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
NCAC 15A 8G .0201
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Facility Name: WHISTLE STOP
Permit # NCO067326
Facility Type/Classification: WW Facility Grade: II SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: James Vanderwonde
Email Address: JVW(aDR.co
Permittee Signature:
Full Name: John C. Brown
Date: � - / -
Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: WW
Certificate Grade: II
Certificate #: 1014546
Signature: �i-s�..� Effective Date: D� /i Nc� fZt�
'9 certify that I agree te'Firy 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 WPC5OCC'
Full Name: Wanda G. Ladd
Certificate Type: _WW
Backup ORC
Certificate Grade: II
Work Phone: [phone]
Certificate #: 10520
Signature: Effective Date: —�
"i certify that / agree to my designation as the Operator in Responsible Charge for the facility noted. / 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 WPCSOCC"
Backup ORC
Full Name:
Certificate Type: Select Certificate Grade: Select
Work Phone:
Certificate #:
Signature:
Effective Date:
"I certify that 1 agree to my designation as the 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 WPCSOCC"
Email this form to: certadmin@deq,nc.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: Asheville-2090 US Hwy 70, Asheville, NC 28778 1 FAX: [phone] PH: 828-296 4500
Use the 2nd page only if you need to list additional Backups.
Revised 002024