WQ0005910_Other_20200512

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Augustinus Gerritsen
Email Address: [e-mail]
Permittee Signature: Date: 0 120Z Q
Facility Name: Avoca LLC Permit # WWO05910
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SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: VW
Facility Grade: fish s'Old
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ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Brian McKinley Conner Work Phone: [phone]
Certificate Type: WW
Certificate Grade: II
Email Address: [e-mail]
Certificate #: 993283
Signature: (� Effective Date:
"I certify that 1 agree to my designation as the 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: Bobby Nelson Byrum Work Phone: [phone]
Certificate Type: WW
Certificate Grade: I
Email Address: [e-mail]
Certificate #: 1008642
Signature: Effective Date: 5-0—c);D
"I 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."
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 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. 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