NC0088722_Other_20200123

01-23-'20 10:49 FROM-
T-005 P0001/0002 F-007
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 1SA SG -0201
Press TAB to enter information
Permittee Owner/Officer Name: Donald V. Chamblee
Mailing address: 115 West Main Street
City: Lincolnton
state: NC
Phone: [phone]
Zip: 28092
Email Address: acnambleeg[Dlincolncounty.org
Signature: DA 0 Date: j CA/2c>
Facility Name: Killian Creek WWTP
County: Lincoln
Permit # NC 0088722
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW
Facility Grade: III
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: James T. Simmons Work Phone: [phone]
Certificate Type: WW
Email Address: tsim
Signature:
"I certify that I
rules and reaui
Certificate Grade: IV Certificate #: 1001451
nty.org
Effective Date: I
y designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the
lining to the responsibilities of the ORC as set forth In 15A NCAC 086 .0204 and failing to do so can result in
Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name:
Brian A. Koon Work Phone. [phone]
Certificate Type:
WW Certificate Grade: IV Certificate It: 1005670
Email Address:
[e-mail]
Signature:
Effective Date: 11 i lZoZo
"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."
Mail, fax or email
WPCSOCC, 1618 Mail Service Center, Fax: 919-715-2726 €mail: [e-mail]
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 27889 Wilmington, NC 28405-2845 Winston-Salem, NC 27105
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone] Revised4no9s

01-23-'20 10:49 FROM-
T-005 P0002/0002 F-007
WPCSOCC Operator Designation Form (continued)
Facility Name: Killian Creek WVHTP
Permit #: NC 0088722
BACKUP ORC
Print Full Name: Sandra M Craft Work Phone: [phone]
Certificate Type: WW
Email Address:
Signature:
Certificate Grade: IV
.org
Certificate #: 993644
Effective Date: / - 7 -,7o a 6
Page 2
I certify that I agree to my designation as ri(Bjack-up Operator in Responsible Charge for the facility noted. l understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC os set forth in 15A NCAC 08G .0204 and falling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Robert H. Hinson Work Phone:[phone]
Certificate Type: WW
Email Address: chin£
Certificate Grade: III
Certificate #:1007632
Signature: Effective Date: /- -7 — 2,,9,?0
"I certify that I agree to my designation as SBack-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
Email Address:
Signature:
Certificate Grade: Select Certificate #:
Effective Date:
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."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select Certificate It:
Effective Date:
"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 os 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