WQ0015053_Other_20200225

WATER POLLUTION
Permittee Owner/Officer Name:
Email Address:
CONTROL SYSTEM OPERATOR DESIGNATION FORPQWPCSOCC)
NCAC 15A 8G .0201Pre
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Currituck Counttys�/rBAB to enter information
Ben Stikeleather
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[e-mail] ,
�iyon Res se Permittee Signature: Date: e9io� a -'�� r
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Facility Name: Moyock Commons WWTP
Permit # WQ0015053
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: WW
Facility Grade: II
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Roderick Lee Holley
Certificate Type: WW
Certificate Grade: III
Email Address: [e-mail]
Signature:
Work Phone: [phone]
Certificate #: 1009155
Effective Date: Z - 2 S_ - 2m
"I certify that/ agree to my designation as the Operlor 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: William Donnell Orgsbon Work Phone: [phone]
Certificate Type: WW
Certificate Grade: IV
Email Address: Don nel1.Orgsbon@currituck countync.gov
Certificate #: 1006384
Signature: �„l ,s,.r_ Effective Date: Z - 23 - Z 0
"I certify that I agree to my designation as a Back-up Operator in R sponsible 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, Raleigh, NC 27699-1618
ORIGINAL to: Email: [e-mail] Fax: [phone]
Mail or Fax a COPY to: Asheville Fayetteville
2090 US Hwy 70 225 Green St., Suite 714
Swannanoa, NC 28778 Fayetteville, NC 28301-5043
Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone]
Mooresville Raleigh
610 E. Center Ave., Suite 301 3800 Barrett Dr.
Mooresville, NC 28115 Raleigh, NC 27609
Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq. Mall 127 Cardinal Dr. 45 W. Hanes Mill Rd.
Washington, NC 27889 Wilmington, NC 28405-2845 Winston-Salem, NC 27105
Fax: [phone] Fax: [phone] Fax: [phone] Phone:
Phone: [phone] Phone: [phone] Revised 512019