NC0081931_Operator Designation_20180813

RECEIVEDINCDENRIDWR `
WATER POLLUTION ONTROL SYSTEM OPERATOR DESIGNATION FORM (WPC�O1Cs)2018
NCAC 15A 8G.0201
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Permittee Owner/Officer Name: ICube Yadkin Generation LLC / John Collins MOORESVILLE REGIONAL OFFICE
Mailing Address: 12 Bethesda Metro Center, Suite 1330
City:
Email Address:
Signature:
Facility Name: High Rock
State: MD
Phone:
[phone]
Zip:
20814
q. Mall
127 Cardinal Dr.
Washington, NC
Date:
7/a6 /ao)g
Permit# NCO081931
County: Davidson
YOU MUST SUBMIT A SEPARAT FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Grade: 11
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Jeffrey Todd Henley Work Phone: [phone]
Certificate Type: PC Certificate Grade: I Certificate #: 990459
Email Address: jhenley@Cube arolinas.Com
Signature: Effective Date: I17—OIZ-0 )
"I certify that I agree to my designatio as the Operator in Responsible Charge for the facility noted. 1 understand and will abide by the
rules and regulations pertaining to th 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 Pollu ion Control System Operators Certification Commission."
Print Full Name: Phillip James
Certificate Type: PC
Email Address: PP(
Signature:
"I certify that I agree to my desigfiatioi
the rules and regulations pertaining to
Disciplinary Actions by the Water Pollu
Mail, fax or email
ORIGINAL to:
WPCSOCC, 1618
Raleigh, NC 276'
BACKUP ORC
Certificate Grade: I
Work Phone: [phone]
Certificate #: 987100
llI 11'7)£1.C(� Effective Date: 0 0 w
a Back-up Operator in Responsible Charge for the facility noted. I understand 4d will abide by
responsibilities of the ORC as set forth in 15A NCAC 08G.0204 and failing to do so can result in
Control System Operators Certification Commission,"
I Service Center, Fax: [phone] Email: [e-mail]
Mail or Fax Asheville Fayetteville
a COPY to: 2090 US Hwy 70 225 Green St., Suite 714
Swannanoa, NC 8778 Fayetteville, NC 28301-5043
Fax: [phone], 3 Fax: [phone]
Phone: [phone] Phone: [phone]
Washington
Wilmington
943 Washington
q. Mall
127 Cardinal Dr.
Washington, NC
7889
Wilmington, NC 28405-2845
Fax: [phone]
5
Fax: [phone]
Phone: [phone] Phone: [phone]
Mooresville
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]
Revind 412016

WPCSOCC Operator Designation Form
Facility Name: High Rock
Print Full Name:
Certificate Type: Select
Email Address:
Signature:
"I certify that I agree to my designatioi
the rules and regulations pertaining to
Disciplinary Actions by the Water Pollu
Print Full Name:
Certificate Type: Select
Email Address:
Signature:
"i certify that I agree to my designa,
the rules and regulations pertaining
Disciplinary Actions by the Water Pc
Print Full Name:
Certificate Type: Select
Email Address:
Signature:
"I certify that I agree to my designati
the rules and regulations pertaining i
Disciplinary Actions by the Water Pol
Print Full Name:
Certificate Type: Select
Email Address:
Signature:
certify that I agree to my designatia
the rules and regulations pertaining tc
Disciplinary Actions by the Water Polit
Page 2
Permit #: NCO081931
BACKUP ORC
Work Phone:
Certificate Grade: Select Certificate #:
Effective Date:
as a Back-up Operator in Responsible Charge for the facility noted. /understand and will abide by
he responsibilities of the ORC os set forth in 15A NCAC 08G .0204 and failing to do so can result in
on Control System Operators Certification Commission."
BACKUP ORC
Work Phone:
Certificate Grade: Select Certificate #:
Effective Date:
as a Back-up Operator in Responsible Charge for the facility noted. /understand and will abide by
he responsibilities of the ORC os set forth in 15A NCAC 08G .0104 and failing to do so can result in
on Control system Operators Certification Commission.'
BACKUP
Work Phone:
Certificate Grade: Select Certificate #:
Effective Date:
as a Back-up Operator in Responsible Charge for the facility noted. /understand and will abide by
he responsibilities of the ORC as set forth in 15A NCAC 08G. 0204 and jailing to do so can result in
on Control system Operators Certification Commission."
BACKUP ORC
Work Phone:
Certificate Grade: Select Certificate #:
Effective Date:
as a Back-up Operator in Responsible Charge for the facility noted. /understand and will abide by
he responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to do so can result in
'on Control System Operators Certification Commission."
Revised 412016