NC0020443_Other_20200319 (2)

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name: Z7 w&-l>//�- , A C
Mailing Address:�03/�IA/Nr ; �?1/ l� 36 f Phone: A_5�7 7!& l-27X/
City: �Lw,3�.K State: /vim Zip: 27�2s
Email Address:
Signature:
Date: i
Facility NameoL� l#- �'//id,�4/d7 74�"-7' �T Permit# �� ®42�y �
County: ��^re.(� G
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW
Facility Grade: �11
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Ad e fjGj f Av e� �Q6-p st � Work Phone: CAT 'Z, 7Z* — J(rCC
W Certificate Type: WCertificate Grade: II Certificate #:
Email Address:4 l Ga C'�fC� !n �� • Ce��h
Signature:���__ ., Date:
"I certify that/ 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."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Date:
"/ certify that / 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 asset 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: [phone] Email: [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]
Revised 412016