NC0024911_ORC Designation Form_20171211

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Metropolitan Sewerage District of Buncombe County North Carolina
Mailing Address: 2028 Riverside Drive
City: Asheville
Email Address: [e-mail]
Signature:
Facility Name: French Broad River WRF
County: Buncombe
State: N C
Phone: [phone]
Zip: 28804
Date:
Permit # NC0024911
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW
Facility Grade: IV
Print Full Name: Peter C. Weed
Certificate Type: WW
Email Address
Signature:
[e-mail]
Work Phone: [phone]
Certificate Grade: IV Certificate #: 21201
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 OSG .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Print Full Name: Roger Edwards
Certificate Type: WW
Email Address: [e-mail]
Signature:
Certificate Grade: IV
Work Phone: [phone]
Certificate #: 9926
Effective Date:
"I certify that /agree to7my f�esignation as a Back-up 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."
__
Mail, fax or email
ORIGINAL to:
Mail or Fax
a COPY to:
WPCSOCC, 1618 Mail Service Center,
Raleigh, NC 27699-1618
Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Fax:[phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone: [phone]
Washington Wilmington
943 Washington Sq. Mall 127 Cardinal Dr.
Washington, NC 27889 Wilmington, NC 28405-2845
Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone]
Mooresville
Email: [e-mail]
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 4/2016

WPCSOCC Operator Designation Form (continued)
Facility Name: French Broad River WRF
Permit #: NCOO24911
Print Full Name: Dwayne Martin Work Phone: [phone]
Certificate Type: WW
Email Address: [e-mail]
Signature:
Certificate Grade: IV
Certificate #: 22527
Effective Date:
Page 2
"1 certify that 1 agree to m3�designation as a Back-up 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 OSG .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Print Full Name: Thomas Good Work Phone: [phone]
Certificate Type: WW
Email Address: tgoo�@msdbc.org
Signature:
Certificate Grade: IV
Certificate #:20717
Effective Date:
"1 certify that to my designation as a Back-up 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."
Print Full Name: Joseph Lassiter
Certificate Type: WW
Email Address:
Signature:
jlassiter@msdbc.
Certificate Grade: IV
Work Phone: [phone]
Certificate #: 11695
Effective Date:
"1 certify tha�gree to my designation as a Back-up Operator in Responsible Charge for the facility noted.
the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC OSG .
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
1 understand and will abide by
0204 and failing to do so can result in
Print Full Name: Todd Moore Work Phone: [phone]
Certificate Type: WW
Email Address: [e-mail]
Signature:
Certificate Grade: IV
Certificate #:1001253
Effective Date:
"1 certify that 1 agree to resignation as/ Back-up 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."
Revised 4/2016

WPCSOCC Operator Designation Form (continued)
Facility Name:
French Broad River WRF
Permit #: NCOO24911
Print Full Name: Judd Gregory Work Phone: [phone]
Certificate Type: WW
Email Address: [e-mail]
Signature:
Certificate Grade: IV
Certificate #:1000832
Effective Date:
Page 2
"1 certify that I a e to my desig 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."
Print Full Name: Melanie Sprinkle Work Phone: [phone]
Certificate Type: WW
Email Address: [e-mail]
Signature:
Certificate Grade: IV
Certificate #: 24669
Effective Date:
"1 certify that 1 agree to my designation a.� a Back-up 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."
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select
Certificate #:
Effective Date:
"I certify that 1 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 15A NCAC OSG .0204 and failing to do so can result in
DisciplinaryActions by the Water Pollution Control System Operators Certification Commission."
Print Full Name:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select
Work Phone:
Certificate #:
Effective Date:
"1 certify that 1 agree to my designation as a Back-up 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."
Revised 4/2016