WQ0032289_ORC Designation Form_20241008

Docusign Envelope ID: 4A115F12-EDFE-4284-B587-B2BF28B200A8
Water Pollution Control System OPERATOR IN RESPONSIBLE CHARGE (ORC) Designation Form
Facility Name:
NCAC 15A 8G .0201
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UTLEY CREEK WATER RECLAMATION FACILITY Permit # WQ0032289
Facility Type/Classification: SI
Permittee Owner/Officer Name
Facility Grade: NIA
Town of Holly S
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION
Email Address: [e-mail]
DocuSigned by:
Permittee Signature: FDate: 10/6/2024 1 9: 58 AM PDT
A3HE125CVC4AE...
ORC
Full Name: Terry Ray Foster
Work Phone: [phone]
Email Address: terry.foster@hollys�pEingsnc.gov
Certificate Type: Sl Certificate Grade: N/A
Certificate #: 23920
Effective Date: /rrj' %/a!`-/
Signature:
_
"! certify that! agree to my designation a Operator n 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"
Backup ORC
Full Name: Casey Denton
Work Phone: [phone]
Certificate Type: Sl Certificate Grade: N/A
Certificate #: 1007998
Signature:
Effective Date:
"l certify that i agree to 4 designs ' a e erator in Responsible Charge for the facility noted.
l understand and will abide by the rules and regulations pertaining
to the responsibilities of the ORCaf set forth in 15A NCAC 08G .0204 and failing 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:
'9 certify that i agree to my designation as the Operator in Responsible Charge for the fatuity 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: [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:iChoose DWR Regional Office that has coverage of this facility.
Use the 2nd page only if you need to list additional Backups.
Revised 0212024

Docusign Envelope ID: 4A115F12-EDFE-4284-13587-132BF2813200A8
Facility Name: UTLEY CREEK WATER RECLAMATION FACILITY Permit #: WQ0032289
Backup ORC
Full Name:
Work Phone:
Certificate Type: Select Certificate Grade: Select
Certificate #:
Signature:
Effective Date:
"l 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 1SA NCAC08G .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 cerhtfir thnt f n reP to my desinnntinn ns the OpPrntnr in Resnnncihle Charnr fnr the fnrilih noted.
1 +mdPrstnn f nn i Will nhi !e by the rrr7es and renr+lrrtlnns nertnin „
to the responsibilities of the ORC as set forth in 15A NCAC O8G .0204 and failino to do so can result in Disciplinary Actions by the WPCSCCC
Backup ORC
Full Name:
Work Phone:
Certificate Type: Select Certificate Grade: Select
Certificate #:
Signature:
Effective Date:
I certify that ! agree to my designation as the Operator 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 NCACORG.0204 and failing 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:
"! certify that! agree to my designation as the Operator 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 NCACO8G .0204 and failing to do so can result in Disciplinary Actions by the WPCSOCC"
Revised 0212024