WQ0016165_Other_20191202

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name: _ [� 51
8
n
�oNC
•1oG�riS'?
Mailing Address: QS k>ts� clfKaer
st
City: -o%54tw-, State: t c Zip: mia-
Email address: _� e�l.1600, t �+l1L: erl 11C • S ey
Phone #: 334~ o14 b " 31?,a(P
Signature: _ Date: l.21a [ 17
Facility Name: 1tKjag4dot RR4 r0r .I w (a7-P Permit #: dC o0s.SM.
County:_ -Dk a Ors
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
✓Biologic Collection Physical/Chemical Surface Irrigation Land Application
Operator in Responsible Charge (ORC)
Print Full Name: Sfe- Cr t.,7 Crower /Email: SC Croonr ® (e t6!bf 6A r)C . _9a
Certificate TyIPIAI,A,�
rade / Number: (i� �% r I �`f Work Phone #: 3 3 (4- 3SrI - SO p
Signature: �� Date:
"I certify that I agree to my designation as th perator 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."
.................................................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: !�Uota 5 U-0h#46664 Email: f 4 ; 060kso-, (9 [q�„�J-biz_ne . y o d
Certificate Type / Grade / Number: ! 2 W,* Work Phone #: 334- J49 - 39j2 F
Signature: ], N"` Date: l-2 -•0 • I g
"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 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
original to:
Mail or fax a copy to the
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
Email: certadmin(d.ncdenneov
Asheville
Fayetteville
2090 US Hwy 70
225 Green St
Swannanoa 28778
Suite 714
Fax: [phone]
Fayetteville 28301-5043
Phone:[phone]
Fax:[phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
Raleigh
610 E Center Ave
3800 Barrett Dr
Suite 301
Raleigh 27609
Mooresville 28115
Fax: 919.571A718
Fax:[phone]
Phone:[phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Revised 05-2015