WQ0001284_ORC Designation Form_20240912 (3)

12. 2024 2; 32PM fl�o, �� 12 P. J.
vvrl r cn PULLU r ION CONTROL SYSTEM OPERATOR DESIGNATION FOI<rvr kvvr'CSU� k-)
NCAC 15A 86.0201
Permlttee Owner/Officer Name:
Mailing Address:
Press TAB to enter information
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City; 0Q7�'t!_iL.t State:
Ern aiI Address; f -r7vx�rzipr,bh6np -
Facility Name: lI.. 1
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Phone;�5$S'QY88
Zip; a78'2�J
Date;
Permit # 6 00 a- 9,-f
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM.
Facility Type: (elf U.)
Facility Grade: I
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name; 'T,,p f-f q FAr i T,,.r,t,r' Work Phone: 059 - 35Cr - lyq 7
Certificate Type: Certificate Grade: Certificate #: 101 t-IHi-IW
Email Address: -fir, A Au ecr l &- -,o,
Signature:
Effective Date: q — 5"a62!-j
"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 falling to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commisslon,"
BACKUP ORC
Print Full Name: rS2 �- IL y CA kon Sc�, Work Phone: zs'2_)30T -'�9•Q y
Certificate Type: Select S Certificate Grade: Select Certificate #; 9V IJS-
Email Address: ' e a �>' , C ci n,
Signature: Effective Date:
"I certify that I agree tPmydeslgriack-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
Disciplinay Actions by the Water Pollution Control System Operators Certification Commission."
Mall, fax or email WPCSOCC,1618 Mall Service Center, Fax; 919-715-2726
ORIGINAL to: Raleigh, NC 27699-1618
Mall or Fax Asheville
a COPY to: 2090 US Hwy 70
Swannanoa, NC 29778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Or,
Wilmington, NC 20405-2845
Faw 910-350-2004
Phone; 910-796-7215
Email: certadmin@ncdenr,gov
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax; 704-663-6040
Phone; 704-663-1699
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax; 336-776-9797
Phone; 336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax; 919-571-4718
Phone;919-791-4200
Revised 40016