NC0025861_Other Agency Documents_20200303

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name: l b o m o s E. S kr e w 5 b txry P" 6 t i C Works D t V
Mailing Address: C i 1- c>� Lo w e ( 1 101 W. F iw s-t 5f .
City: Lowe -it State: N C Zip: 2 70 1 S- Phone k 70 41%$ 2,4- 3 5'/ 8
Email address: 't S% rew 5 b 1A r 1 o wa 1 t VIC- Co m
Signature: Date: 3 3 ZG>
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Facility Name: C � )-ov W W T P Permit #:�-44441.2 6
County: V g's K
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SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
Biological X Collection Physical/Chemical Surface Irrigation Land Application
............................................................................................................................................
Operator in Responsible Charge (ORC) N,4eALI
Print Full Name: 1 � ,E.� ����5 Email: d a,4 11 ew CC))gA
Certificate Type / Qrade / Number: ' Ll 188573 Work Phone #: a 7 .7 Z ^ SS
Signature: G Quk—Date: 3 Z
`'I certify that I agree to my designation as 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."
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Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: W; It i ayh Alexan jer �0.y ttieS Email: w m °t r` �'-5 o1'�n a ' 1 . c a w'
Certificate Type / Grade / Number: W Wt Zr 10 O 0 &7 Work Phone #: 7 a 14/ b l 4_ to 7 2 q
Signature: WA!�Cit/l,. Date: Z
"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 thexesponsibilities 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"
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Y. fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 276994618 Fax: [phone]
original to: Email. certaft ' @ncdear gov
Mail or fax a copy to the Asheville
Fayetteville
Mooresville
Raleigh
appropriate Regional Office: 2090 US Hwy 70
225 Green St
610 E Center Ave
3800 Barrett Dr
Swannanoa 28778
Suite 714
Suite 301
Raleigh 27609
Fax: [phone]
Fayetteville 28301-5043
Mooresville 28115
Fax: 919.571A718
Phone:[phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:704,663.16"
Washington
Wilmington
Winston-Salem
943 Washington Sq Mall
127 Cardinal Dr
450 W. Hanes Mall Rd
Washington 27889
Wilmington 28405-2845
Winston-Salem 27105
Fax:[phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Revised 05-2015