NC0055336_Delegated Authority_20200326

TION
Permittee Owner/Officer Name:
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Permittee Signature: /— �{'
Facility Name:
CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Date: �J3��2jj
Permit # ArCGXS5 5X
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: Select
Facility Grade: Select
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Donald G. Byers Work Phone: [phone]
Certificate Type: WW El Certificate Grade: IV 0 Certificate #: 10939
Email Address: byerse"[e-mail]
Signature: Effective Date: 03 / f �2
"I certify that/ agree to my designation as the Op ator 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: Sheridan Byers Work Phone: [phone]
Certificate Type: WW El Certificate Grade: I 0 Certificate #: 992889
Email Address: [e-mail]
Signature:
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."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
ORIGINALto: Email: [e-mail] Fax:[phone]
Mail or Fax a COPY to: Asheville
Fayetteville
2090 US Hwy 70
225 Green St., Suite 714
Swannanoa, NC 28778
Fayetteville, NC 28301-5043
Fax:[phone]
Fax:[phone]
Phone:[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]
Washington Wilmington Winston-Salem
943 Washington Sq. Mall 127 Cardinal Dr. 45W. Hanes Mill Rd.
Washington, NC 27889 Wilmington, NC 28405-2845 Winston-Salem, NC 27105
Fax:[phone] Fax:910-3S0-2004 Fax:[phone] Phone:
Phone:[phone] Phone:[phone] Rev/sed5/2019