WQ0002096_Other_20200420

RECEIVED APR 2 01010
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Guy Pierce
Email Address: [e-mail]
Permittee Signature: Date:
Facility Name: Ahoskie Assisted Living
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM:
Permit # W00002096
Facility Type: SI
Facility Grade: N/C
I ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Randall D. Parker
Certificate Type: SI
Email Address: rdparnpobX@g
Certificate Grade: Select
cam
Work Phone: [phone]
Certificate #: 996843
Signature: Effective Date:
"9 certify that / agree to my designation as the Operator in Responsible Charge for the facility noted. / 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."
Print Full Name: Amy M. Pierce
Certificate Type: SI
Email Address:
BACKUP ORC
Certificate Grade: Select
[e-mail]
Work Phone:
Certificate #:
252-287-6711
993127
Signature: �tomy
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- � � Effective Date: � � �����
'7 certify that I agree de gnation as a Back-up Operator in Responsible Charge for the facility noted. / 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: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax:[phone]
Phone:[phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 512019