WQ0029894_Other_20200427

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WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPftf4;)
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NCAC 15A 8G .0201
Press TAB to enter
Permittee Owner/Officer Name:
Email Address:
Permittee Signature: � v""� Zao"xj_f, W .
APR 3 0 2020
Facility Name: AfJ Q�l/ �/�%� a/iVK/ / %D Permit # I'dio
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: WW
Facility Grade: II
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Io ly IFS dA141-11 Work Phone: 2<2- 7ZZ - //09
Certificate Type: WW Certificate Grade: II _ Certificate #: "246,03
Email Address: _ o�ANt P C 0A")'CDywi Ae. 44✓
Signature: Effective Date: 2"1-Z020
"1 certify that I agree to rlywslgnation 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."
Print Full Name: Ou j a (.-
Certificate Type: WW
Email Address: COLS
BACKUP ORC
Certificate Grade: III
Work Phone: 2,' 7--2,07 �oFT,,t
Certificate #: 9 q 4-3 5/
Signature: "P'1M-t_lJ"4_1124' Effective Date: -�/ Z-717-0
"i certify that 1 agree to my designation as a Back-up Operotot 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::: t:E:r i:,f �nrnr.o, Fax: [phone]
Mail or Fax a COPY to: Asheville
Fayetteville
Mooresville
Raleigh
2090 US Hwy 70
225 Green St., Suite 714
610 E. Center Ave., Suite 301
3800 Barrett Dr.
Swannanoa, NC 28778
Fayettev:lle, 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 Mill Rd.
Washington, NC 27889 Wilmington, NC 28405-2845 Winston Salem, NC 27105
Fax: [phone] Fax: [phone] Fax: [phone] Phone:
Phone:[phone] Phone:[phone]
Revised 512019

Facility Name:
Certificate Type: WW
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Permit #:
�'9at-aid
Work Phone: (?,'t)333 -'7 S%L
Certificate Grade: II Certificate #: /DD
Email Address:�`f!/D ��}��I✓GONNi/G. God
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Signature: Effective Date: Y-24- ZVZO
"1 certify that / agree o 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 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
Email Address:
Signature:
Certificate Grade: Select Certificate #:
Effective Date:
"l certify that / agree to my designation as a Bock -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 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 I
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select Certificate #:
Effective Date:
"/ certify that / agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. 1 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
Email Address:
Signature:
Certificate Grade: Select Certificate #:
Effective Date:
"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 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."
Revised 512019