NC0021229_Other Correspondence_20200601

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNip
NCAC 15A 8G .0201
Press TAB to enter information JUN 0 i 2020
Permittee Owner/Officer Name: Town of Old Fort, Mayor Rick Hensley
Email Address: [e-mail],
Permittee Signature:
Facility Name: Town of Old Fort WWTP
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM:
Print Full Name: Anthony Glenn West
Certificate Type: WW
Email Address:
Signature:
-OPERATOR IN
Certificate Grade: IV
Date: J - a 7-- � Q
Permit # NCO021229
Facility Type: WW
Facility Grade: III
Work Phone: [phone]
Certificate #: 23524
Effective Date: 5 - - Co = uj
"1 certify that I agree to my designation as Re 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."
I BACKUP ORC 1
Print Full Name: Aaron Vess Work Phone: [phone]
Certificate Type: WW Certificate Grade: 11 Certificate #: 1009465T
Email Address: [e-mail]
Signature: B�,� U Q AA Effective Date: .5 , (o , Q
"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 ISA 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 Mooresville Raleigh
2090 US Hwy 70 225 Green St., Suite 714 610 E. Center Ave., Suite 301 3800 Barrett Dr.
Swannanoa, NC 28778 Fayetteville, 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] Relased&2019