WQ0024320_WPCSOCC designations_20190222

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15/A 8G.0201 /)
Permittee Owner/Officer Name: A�R _1.Rt C / SArIIC S R• 13ol Liz
Mailing Address::/ ,U . 13W a 3�9
city: .st,"ibestiU State: 4/C Zip:Rfi S0 q _ jq 3c,5 Phone#: as o2 - 393 g 5to
Email address: It 6P �/tlG,t,�- 60 f
Signature: Date: it ,4�
....................... ..y ........................................................... ............................. .................
Facility Name: FK� i3�IJg6S/[) Permit#: 1 if OD g3QO
County: �R�A✓<G _
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade(CHECK ONLY ONE):
r(gIl Collection Physical/Chemical Surface Irrigation Land Application
................ ........ ......................................................................................................... x
Operator in Responsible Charge(ORC) n
O
PrintFlillName: a[xi�S gza4 tall kw 5le- Email:_Dol6Wtk�(6S �y Qr1�tI tccwr 2.
�'1 0
-n
Certificate Type/Grade/Number:WM M f 2Rr122 Work Phone#: 1?19 A1-`aS oS y CD 7
gn
as
Si attue: Date: 9- (9-/8
IV
Ieenify that I agree to my designatio tithe Operator in Responsible Charge for the facility noted.I understand and will abide by the rule xC"p
and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 080.0204 and failing to do so can result N Disciplt y m
Actions by the Water Pollution Control System Operators Certification Commission."
............................................................................................................................................... ..n` A
Back-Up Operator in Responsible Charge(BU ORC)
Print Full Name:�.✓x/[S v cna'r / il'K/ T Email: J re.�t l'TK Q3 cy mRt 1.
Certificate Type/Grade/Number: MV = Work Phone#: Of? )
Signatur� Date: y- fT-/9
"I certify that 1 agree to my designation as a ack-up Operator in Responsible Charge for the facility noted.I understand and will abide by the
rules and regulations pertaining to the respons ilities of the BU ORC as set forth in 15A NCAC 08G.0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
'
Mail,fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh,NC 27699-1618 Fax: [phone]
ori,eina[to: Email: certadmima',ncdenngov
Mall orfax a cony to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 225 Omen St 610 E Center Ave 3800 Barrett Or
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:[phone]M Fax:910A86.0707 Fax:[phone] Phone:[phone]
Phone:[phone] Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Or 450 W.flans Mall Rd
Washington27889 Wilmington28405.2845 Winston-Salem27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:910.7%.7215 Phone:[phone]
Revised 05-2015

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8/C.0201
Permittee Owner/Officer Name: J T;,IC . / )Flmc S
Mailing Address: i• C) -ew '�
City: ..S�S bi i (3 State: tt/CZip: - 2369 Phone#: a5Q - 34 3 - 656 R
Email address: [e-mail]
Signature: Date: 2/20/19
Facility Name: l2 t�Rt �................................................................................Permit#:...146OQ ` 52c)
County: (410 k&
...................................................................................................................................................
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade(CHECK O
Biological Collection Physical/Chemical rface Irrigation Land Application x
n
O
Operator in Responsible Charge(ORC) m
Print Full Name: I rri
i : j . rr
N <
�• iv o
Certificate Type/Grade/Number: MVP o 93 Work Phone#: 9/9 (aR/- ,2SOS- c
_ 9
Signattlre� ��. Date: '9-
"1 certify that I agree to my desigrua the Operator in Responsible Charge for the facility noted.I unders10
tand and will abide by the r s
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 bvtheWaterPollutionControlSystemOperatorsCertifiicationCommis ... ".. "Commission." ., .' •...••... .•••.....'•-...••.... 4z
. . .
Back-Up Operator in Responsible Charge(BU ORC)
Print Full Name: James Roderick Butler Email: [e-mail]
Certificate Type/Grade/Number: SI 22770 Work Phone#: [phone]
Signature: Date: 0 2/2 0/1 9
"I certify that I agr 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 BU ORC as set forth in 15A NCAC 08G.0205 and failing to do so cart result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
....................................................................................................................................................
Afa/l,fax or email the WPCSOCC, 1618 Mail Service Center, Rnleigh,NC 27699-1618 Fax:[phone]
orleinnl to. Email:certadmili .nedenr.sov
Mail orfara coop totire Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office. 2090 US Hwy 70 225 Green St 610 E Center Ave 3800 Barren Dr
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax:[phone] Fayetteville 28301-5043 Mooresville 28115 Fax:[phone]
Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone]
Phone:[phone] Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Or 450 W.Hanes Matt Rd
Washington27889 Wilmington28405-2845 Winston-Salem27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
Revised 05-2016

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter information
PermitteeOwner/Officer Name: 621 — -kic /TA,mLS F. 0,l44ElZ
Mailing Address: 2.6- ?ydd� Phone:
City cScU yc 00to State: M1IL zip:
Email Address: Al C LI�r
Signature: Date: 'L-/ZO /
Facility Name: I_6Clc6'ld _ S f _ Permit# IA1066'Q43 20
County: lkI /�
NC Dept of Environmental Quality
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM: FEB 2 2O19
Facility Type: Select Cc 1�Cc
Facility Grade: .Select
Raleigh Regional Office
OPERATOR IN RESPONSIBLE CHARGE(ORC)
Print Full Name: John Poteat Work Phone: [phone]
Certificate Type:CS Certificate Grade: III Certificate#: 22359
Email Address: [e-mail]
Signature: 1 _� �✓ / s Effective Date. e
"!certify that I agree to eslgnation os 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: n,_ CC1.,e J \�.0 t�.�,g�� C X�� '� Work Phone:
Certificate Type:Select Certificate Grade: Select Certificate pq:'i 99
Email Address: CK14CIC1Or qA 17 60T-C L0 , (t
Signature: Q� Effective Date: i -%5- I`l
-1 certify that I agree to my designation as a Bock-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 Control System Operators Certification Commission."
Mail,fax or email WPCSOCC,1618 Mail Service Center, Fax:[phone] Email:Certadminancdenr.gov
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 27899 Wilmington,NC 28405-2845 Winston-Salem,NC 27105
Fax:[phone] Fax:910-35D-2004 Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]