WQ0000185_Operator Designation Form_20200225

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION
Permittee Owner/Officer Name:
Email Address:
NCAC 15A 8G .0201
Press TAB to enter information
Currituck County/ Ben Stikeleather
FORM I;�OCC)
dF
[e-mail]
Permittee Signature: JA
Facility Name:
Ocean Sands WWTP
Date:
Permit # WQ0000185
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: WW
Facility Grade: IV
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: William Donnell Orgsbon Work Phone: [phone]
Certificate Type: WW
Certificate Grade: IV
Email Address: [e-mail]
Certificate #: 1006384
Effective Date: — 2. co
Signature: I,,,,J .,AQ..,q,.,,.�. k} O Z - 2 S
"I certify that I agree to my designation as the Operator in Re ponsible 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: Roderick Lee Holley Work Phone: [phone]
Certificate Type: WW Certificate Grade: III Certificate #: 1009155
Email Address: [e-mail]
Signature:
Effective Date: Z - 2 5 — Z--D
'1 certify that I agree to my designation as a Back-up Operdtor 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, Raleigh, NC 27699-1618
ORIGINAL to: Email: [e-mail] Fax:[phone]
Mail or Fax a COPY to: Asheville
2090 US Hwy 70
Swannanoa, 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: 910, 796-7215
Mooresville Raleigh
610 E. Center Ave., Suite 301 3800 Barrett Dr.
Mooresville, NC 28115 Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800
Fax: [phone]
Phone: [phone]
Revised 512019