NC0081621_Operator Designation_20180801

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Travis Mark Fowler
Mailing Address: 6400 Breezy Lane
city: Concord
Email Address: mf\o/Wler WSacc,ori
Signature: � V� w
Facility Name: Muddy Creek WWTP
County: Cabarrus
Phone: [phone]
State: NC Zip: 28025
Permit# NC0081621
YOU MUST SUBMITA SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW Q
Facility Grade: II 0
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Kimberly D. Holt Work Phone: [phone]
Certificate Type: WW
Email Address: [e-mail]
Q Certificate Grade: IV 0 Certificate #: 993802
Effective Date: 7- 10
'7 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: John Walter Ritchie Work Phone: 704-78&41164, x114
Certificate Type: WW Q Certificate Grade: IV Q Certificate #:990814
Email Address: [e-mail]
Signature: /S AA ���� Effective Date: Z�FL
"7 certify that I agree filmy 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 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
Swannanoa, NC 28778
225 Green St., Suite 714
Fayetteville, NC 28301-5043
610 E. Center Ave., Suite 301
Mooresville, NC 28115
3800 Garrett Dr.
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]
ReNsed 4/2016

WPCSOCC Operator Designation Form (continued) Page 2
Facility Name: Muddy Creek WWTP Permit #: NCO081621
BACKUP ORC
Print Full Name: dames Christian Sims Work Phone: [phone], x118
Certificate Type: WW LLJ Certificate Grade: IV 0 Certificate #:999309
Email Address: [e-mail]
Signature: Effective Date: 26
"1 certify that I agree tgfny 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."
BACKUPORC
Print Full Name: Matthew Dwayne Isenhour Work Phone: [phone], x118
El
Certificate Type: WW
Email Address: misenhour@
wsacc.org
Certificate Grade: IV El Certificate #:1002601
Signature: (� G t Effective Date:
"I certify that/ agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. /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: Karen Renee Marie Work Phone: 704m7884164, x118
Certificate Type: WW Q Certificate Grade: IV Q Certificate #:1002612
Email Address: [e-mail]
Signature: � 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 O8G .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: Christopher Scott Yost Work Phone: [phone], x118 Ej
Certificate Type: WW
Certificate Grade: II Certificate #:1002797
Email Address: [e-mail]
Signature:
Effective Date: 7 � Z )- / $
"I certify that 1 agree to my designation as a Back-uliOperotor in Responsible Charge for [he facility noted. 1 understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in ISA NCAC 086.0204 and failing to
do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
�
Revised 412016

WPCSOCC Operator Designation Form (continued) Page /3
Facility Name: Muddy Creek WWTP Permit M NC0081621
BACKUP ORC
Print Full Name: Jesse Lee Wingler Work Phone: [phone], x118
Certificate Type:
WW
Lzj Certificate Grade: IV
Certificate #:1004838
Email Address:
[e-mail]
Signature:
Effective Date: r_�/C/�/
"1 certify that 1 agre� my desig�iation 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."
BACKUP ORC
Print Full Name: Joseph Thomas Giod �Vf. Work Phone:[phone]
164, x118
Certificate Type: WW El Certificate Grade: IV El Certificate #:'/00 6 NOQ
Email Address: [e-mail]
Signature: Effective Date: %- z �—
"1 certify that I 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 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: Nicholas James Mervin Work Phone: [phone], x118
Certificate Type: WW El Certificate Grade: III El Certificate #:1005194
Email Address: [e-mail]
Signature: �;� ���-y Effective Date: 2
"/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 asset 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: Braden Joshua Cook Work Phone: [phone], x118
Certificate Type: WW El Certificate Grade: IV Certificate #:1002815
Email Address: [e-mail]
Signature:
Effective Date: a-, I? qI 1`0
"I certify that/ agree to my designkion 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 086.0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
ReNsed 412016