NC0040355_ORC_TUFT_20200420

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name: Roll a LAwP.H/YG.6
Mailing Address: a.00 Ge 1&!6,Ake_J. Ed
City: C R/A.,.. State: /VG -Zip: a?i/6 - Phone #:'if- 2-3 S — 84-1S l
Email
Signat
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Facility Name: SoTv%%;s f_ W& -tC Permit#: NC_ 00H0396'-
County: N&thwemd
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SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
Biologicah0 Collection Physical/Chemical Surface Irrigation Land Application
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Operator in Responsible Charge (ORC)
Print Full Name: 141 rogA j; ea .t r TuNT Email: +u.V r. h i'f&m 3 18)y%0.(1 . co, --
Certificate Type / Grade/ Number: W VJ / H i DO 0o 7 Work Phone #: (920-1 yb - /26'9
Signature: ,;.--— /�% Date:_
`9 certify that 1 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) O ���j�
Print Full Name: Email:
Certificate Type / Grade / Number: Work Phone #: APR 20 2020
Signature: Date: 012tcr nl�'AI t„ Regional Operations
certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted.�Sl ianWAWQn96Q the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in I5A 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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Mail, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
orielnal to: Email: certadminAmedenngov
Mail or fax a coov to the
appropriate Regional Office:
Asheville
2090 US Hwy 70
Swannanoa28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 05-2015