WQ0001284_ORC Designation Form_20240912

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name: TOWN OF CONWA`r
Mailing Address: P O BOX 365
L tic t.� :Si - -
Phone: r502 J`r&S^dtlis'8
City: (;UNWAY Slate: NC; Zip: 27820
Email Address: [e-mail] Lt5017 � LoinDo - C.Or»
Signature: Date:Q UW
Facility Name: TOWN OF CONWAY WWTF Permit # WQ0001284
County: NORTHAMPTON
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type:
WW
0
Facility Grade:
11
0
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: TIMOTHY EARL TURNER Work Phone: [phone]
Certificate Type: WW
Email Address:
Signature:
0 Certificate Grade: I
mail.com
Q Certificate #: 1014893
Effective Date: y- 5,- me-/
"I certify that I agree 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
Print Full Name: JEFFEY CARL LONG SR Work Phone:[phone]
Certificate Type: WW Q Certificate Grade: I Q Certificate #:992044
Email Address:
Signature: ` Effective Date
"I certify that/ agree t y design ion as a Back-up Oper for in Responsible Charge for the facility noted. I understand and will abide by
the rules and regulations pertain' g 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, Fax: [phone]
Raleigh, NC 27699-1618
Mail or Fax Asheville Fayetteville
a COPY to: 2090 US Hwy 70 225 Green St., Suite 714
Swannanoa, NC 28778 Fayetteville, NC 28301-5043
Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax:[phone]
Phone:[phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax:[phone]
Phone:[phone]
Email: [e-mail]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax:[phone]
Phone:[phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax:[phone]
Phone:[phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax:[phone]
Phone:[phone]
Revised 4t2016

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter
Permittee Owner/Officer Name:
Mailing Address:
City: c State:
Sr -
J
Email Address: {—mpt i 10+ rd (WI 1p,r�sQCpa nb5r ��4 / (4) ICJ ,t A& 9SZ (^a V4h*0',
Signature: Z Al4a400< Date:
Facility Name: 0.41 Vj at' ps-IA.4 Ant M 6&W7F Permit# Oa 0oo (a2?P
County:
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: w i
Facility Grade: I I
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Tmp4-4.1 Earl Ti t-,_r Work Phone: 059-3,j6-IL-197
Certificate Type: 513Certificate Grade: Certificate #i: I014/11-1 W
Email Address:
Signature:
Effective Date: 9 - 5--ad QH
"I certify that I 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 Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: ;'Q r ILY Cctg,- I kon S'. Work Phone: 2r'2)308'-29$ Y
Certificate Type: Select S t Certificate Grade: Select Certificate g: 9413 /3,5-
Email Address: e F rr mar/ . C o
Signature: Effective Date:
"I certify that/ agree t y designs on 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 WPCSOCC, 1618 Mail Service Center, Fax: [phone] Email: [e-mail]
ORIGINAL to: Raleigh, NC 27699-1618
Mail or Fax Asheville Fayetteville Mooresville Raleigh
a COPY to: 2090 US Hwy 70 225 Green St., Suite 714 610 E. Center Ave., Suite 301 3800 Barrett Dr.
Swannanoa, NC 28778 Fayetteville, NC 28301-5043 Mooresville, NC 28115 Raleigh, NC 27609
Fax:[phone] Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone] Phone:[phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax:[phone]
Phone:[phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax:[phone]
Phone:[phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax:[phone]
Phone:[phone]
Revised 412016

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to a iter in.formation
Permittee Owner/Officer Name: TOWN OF CONWAY - L
Mailing Address: P O BOX 365
City: CONWAY
Email Address: [e-mail]
Signature:
Facility Name: TOWN OF CONWAY WWTF
County: NORTHAMPTON
State: NC
I)AAhe ar= ✓n4�
Phone: o25'?! SW6 (g8
Zip: 27820
Date: q_1 Z ZO zq.
Permit # WQ0001284
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type:
WW Q
Facility Grade:
1
Q
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: TIMOTHY EARL TURNER Work Phone: [phone]
Certificate Type: C S El Certificate Grade: I Q Certificate #: /0 ja & p J
Email Address: [e-mail]
Signature:
Effective Date: 9 - S_Q Z4
"9 certify that / agree 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
Print Full Name:
JEFFEY CARL LONG SR Work Phone:[phone]
Certificate Type:
C $ Certificate Grade. I 0 Certificate M q9©© 7 (1
Email Address:
On
Signature:
Effective Date:
"I certify that 1 agree m desig ation as a Back-up Op rator in Responsible Charge for the facility noted. I understand and will abide by
the rules and regul
ions 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
WPCSOCC,1618 Mail Service Center, Fax: [phone] Email: [e-mail]
ORIGINAL to:
Raleigh, NC 27699-1618
Mail or Fax
Asheville Fayetteville Mooresville Raleigh
a COPY to:
2090 US Hwy 70 225 Green St., Suite 714 610 E. Center Ave., Suite 301 3800 Barrett Dr.
Swannanoa, NC 28778 Fayetteville, NC 28301-5043 Mooresville, NC 28115 Raleigh, NC 27609
Fax:[phone] Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone] Phone:[phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax:[phone]
Phone:[phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax:[phone]
Phone:[phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax:[phone]
Phone:[phone]
Revised 412016