NC0021865_Delegated Authority_20170105 (2)

•
January 5,2017
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
1617 Mail Service Center E(�JDW
Raleigh,NC 27699-1617 RECE�VEDINC®
•
SAN,.1-..
• p2"°9
Subject: Delegation of Signature Authority =' e
TOWN 01?CHADBOURN WWTP • 1yon:0%61 unit
NPDES Permit Number NC0021865 Peatu9
To Whom It May Concern:
. By notice of this letter,I hereby delegate signatory authority to each of the followirig .ndividuals for all
permit applications, discharge monitoring reports,and other information relating to the operations at
the subject facility as required by all applicable federal, state, and local environmental agencies
specifically with the requirements for signatory authority as specified in'15A NCAC 2B.0506.
• Individual#1 Individual#2(([applicable)
Name:.•• • John Brian Stephens
Title: •• • Wwtp Orc
602 North Brown Street
Mailing Ad'd`ress; • Chadbourn,NC 28431
.Physical'Address:. •
ll4,Ifer00' • •
Bniail Aildiess:. ''
[e-mail]
hotmail.com
Offrce.Phone: - - - -
Mobile Pliorie: 910-740- 3632 - -
If you have any questions regarding this letter,please feel free to contact me at 910-654-4148.
Sincerely,
r
aeV1/1
Patrica E. Garrell •
Interim Town Manager/Finance Officer
602 North Brown Street
Chadboum,NC 28431 .
Email Address: Pgan•[e-mail]
910-654-4148
•
cc: Wilmington Regional Office,Water Quality Permitting Section

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WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G.0201
Press TAB to enter information
Permittee Owner/Officer Name: Town of Chadbourn/Patrica E. Garrell
Mailing Address: 602 North Brown Street Phone: [phone]
city: Chadbourn State: NC Zip: 28431
Email Address: [e-mail]
SignaturePG(�jl(((( j Date: / -010/
Facility Name: Town of Chadbourn WWTP Permit B NC0021865
County: Columbus
•
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW
Facility Grade: III
OPERATOR IN RESPONSIBLE CHARGE(ORC)
Print Full Name: John Brian Stephens Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate#l: 1001112
Email Address: fe.a.5prinV wt,Ji-P P. 01 o- 1. C.OW
Signature: 'v`i G ‘"""` 1 �� Effective Date: I- j - 17
"I certify that I agree to my designation as the Operator n 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 O8G.0204 and failing to do so con result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Carl Steven Price Work Phone:[phone]
• • Certificate Type: WW Certificate Grade: II Certificate if:999365
Email Address: [e-mail] "or" [e-mail]
7 Signature: [� Katt Effective Date: . —
"I certify that!agree to my designation 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 1SA 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 Wilmington Winston-Salem
943 Washington Sq.Mall 127 Cardinal Dr. 45 W.Hanes Mall Rd.
Washington,NC 27889 Wilmington,NC 28405-2845 Winston-Salem,NC 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone] RevWsed4/2016