WQ0039488_Operator Designation Form_20200427

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WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCS CC) cID,�L
NCAC 15A 8G .0201
P ess TAB to enteArmation
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Permittee Owner/Officer Name:
Email Address: t jesollf ii? e,4,vJjrAj oajV .Ve_.ap ✓
Permittee Signature: ` CU4i -[, ICAMdf (I to. Date: -q— / Z 7 l "Coo
Facility Name: Ql1/6010-vt R£A U/k/ C�/s'/�%!�/�' Permit # �Q a49 cr9y8_8i
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: WW
Facility Grade: III El
ORC""-OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: _00o 1 & C c r.d (r_ Work Phone: Z $'L— Z07- (o i74-
Certificate Type: WW 0 Certificate Grade: III Q Certificate #:
Email Address: (�(�� i L' pc✓►ldtn C��� [� f1C' 4 OJ / / __
Signature: Effective Date: I Z 71 Z0
"1 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."
BACKUP ORC
Print Full Name: �Ny Zft CnOWAWT Work Phone: 201-7.27-//o9
Certificate Type: WW n 0 Certificate Grade: II 0 Certificate #: 99 2J�
Email Address: COPAIV1 C CA/YAP"-aNt Ar, - 441y
Signature: z��_ Effective Date:
"I certify that 1 agree to m6elignation 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."
Mail, fax or email
ORIGINAL to:
Mail or Fax a COPY to
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Email: [e-mail] Fax: [phone]
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
Raleigh
610 E. Center Ave., Suite 301
3800 Barrett Dr.
Mooresville, NC 28115
Raleigh, NC 27609
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800 Revised 512019

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Facility Name: r�DilR�/!0�lS� Ax �,Irl..����,� Permit #:
Print Full Name:
Certificate Type: W"
Email Address: i
BACKUP'ORC
E Certificate Grade: II
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Work Phone: ZiZ 333-137Z
0 Certificate #: /DO
Signature: {%�„��,�r/j�-- Effective Date: y'Z`/•La20
"I certify that I agree to m�tion 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:
"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."
F BACKUP ORC
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. 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:
"I 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 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