NC0036196_Other_20181227

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: E. Todd Clark
Mailing Address: PO Box 550
City: Newton
Email Address:
Signature:
Facility Name: Clark Creek WWTP
County: Catawba
State: NC
Phone: [phone]
Zip: 28658
Permit # NCO036196
REeEIVEE)lNeIBENRfDWR
DEC 27 2018
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM: WOROS
MOORESVILLE REGIONAL OFFICE
Facility Type: WW
Facility Grade: IV
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: James Eric Jones Work Phone: [phone]
Certificate Type: WW
Email Address: elRn
Certificate Grade: IV Certificate #: 10217
Signature: ` 4D e, Effective Date:
"I certify that I agree t � y designation as theoperator in Responsible Charge for the facility noted. l understand and will abide by the
rules and regulations pe awning to the responsibilities of the ORC asset forth in 15A NCAC 08G .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: Scott Leon Bryan Sr. _ Work Phone:[phone]
Certificate Type: WW
Email Address: spry
Certificate Grade: IV
Certificate #: 985581
Signature: _ Effective Date: 16 16 L100
"9 certify that I agree to my designatillon 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 con result in
Disciplinary Actions by the Water Pollution Controi System Operators Certification Commission."
Mali, fax or email WPCSOCC, 1618 Mail Service Center, Fax: [phone] objjids,rikNnIIrfOlrtotl�rtt`, pR
ORIGINALto: Raleigh, NC 27699-1618
Mail or Fax Asheville
a. COPY to: 2090 US Hwy 70
Swannanca. NC 28778
Fax:[phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax:[phone]
Phone:[phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax:[phone]
Phone:[phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax:[phone]
Phone:[phone]
Mooresville
610E. 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]
R2kvin
3800 Barrett Dr.
Raleigh, NC 27609
Fax:[phone]
Phone: [phone]
Revised 412016

WPCSOCC Operator Designation Form (continued)
Facility Name: Clark Creek VWVTP
Print Full Name: Trevor Lee Farnsworth
Certificate Type: WW
Email Address: tfarn
Signature:
BACKUP ORC
Certificate Grade: III
Permit#: NCO036196
Work Phone: [phone]
Certificate #: 1006839
Effective Date: 1112(i , a -
"I 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."
Page 2
BACKUP ORC
Print Full Name:
Work Phone:
Certificate Type: Select Certificate Grade: Select
Certificate #:
Email Address:
Signature:
Effective Date:
"!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:
Work Phone:
Certificate Type: Select Certificate Grade: Select
---- Certificate #:
Email Address:
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 responsibiiities of the ORC as set forth i; i 1SA 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 flame:
— __ 4'Vork phone:
Certificate Type' Select --- Certifirate Grade: Select --- Certificate--- --
#:
Email Address: —----------
Signature:=ffective Date
"I certi�y that I agree to my designation as a Suck -up Gpera.or in Res p •unsib,e Chan e o, the g f facility rated. I und; rstand and wile aoide 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 412016