WQ0008778_Operator Designation Form_20200610

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
Permittee Owner/Officer Name:
Email Address:
Permittee Signature: K
Facility Name:
NCAC 15A 8G .0201
Press TAB to enter information
Town of Farmvilie RLAP/ David P. Hodgkins
4
Town of Farmville WWTP
Date: G It 2.L0
Permit N WQ0008778
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: LA
Facility Grade: Select
ORC - OPERATOR IN RESPONSIBLE CHARGE — __
Print Full Name: Roberth Nathaniel Roth _ _ Work Phone: [phone]
Certificate Type: LA Certificate Grade: Select Certificate M. 1001672
Email Address: [e-mail]
Signature: Effective Date: _ /i &0
°I 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 falling to do so can result in
Disciplinary Actions by the Water Pollution Control system operators Certification Commission."
BACKUP ORC
Print Full Name: John Andrew Culp Work Phone: [phone]
Certificate Type: LA
Email Address: JUL
Certificate Grade: Select
Certificate tt: 1000733
Signature: r' A% (1__� Effective Date:
"I certify that I agree to designation as d Back-up Operator in Responsible Charge for the facility noted. i understand and will abide by
the rules and regulations pertaining to the responsibilfties of the ORC asset forth in 15A NCAC 09G .0204 and falling to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission.'`
Mall, fax or email WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
ORIGINAL to: Email: [e-mail] Fax: [phone]
Mall 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]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax! 910-350-2004
Phorret 910-796-7215
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax:[phone]
Phone;704-663.1699
Winston-Salem
45 W. Hanes MITI Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone,,
336-776-980D
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
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