NC0069523_ORC designation form_20200506

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Union County Public Works / Bart Farmer
Mailing Address: 4600 Goldmine Rd
City: Monroe
Email Address: [e-mail]
Signature:
Facility Name: Tallwood WWTP
County: Union
State: NC
Phone: [phone]
zip: 28112
Date:
Permit # NCO069523
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW
Facility Grade: II
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: SAMUEL A. LAYTHAM Work Phone: [phone]
Certificate Type: WW
Certificate Grade: IV
Email Address: [e-mail]
Certificate #: 1005930
Signature: Effective Date: 7 0Coe
"I certify that I agree to my designation as the O 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: Jon Page Work Phone: [phone]
Certificate Type: WW
Email Address
Certificate Grade: IV
[e-mail]
Certificate #: 9998
Signature: C ��"-� 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, Fax: [phone] Email: [e-mail]
ORIGINAL to: Raleigh, NC 27699-1618
Mail or Fax Asheville
a COPY to: 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
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone:[phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 412016

WPCSOCC Operator Designation Form (continued)
Facility Name: Tallwood WWTP
Permit #: NCO069523
BACKUP ORC
Print Full Name: Rick Mareth Work Phone: [phone]
Certificate Type: WW
Certificate Grade: I Certificate #:1008059
Email Address: [e-mail]
Signature: Effective Date: -y a`d-a0
Page 2
"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."
BACKUP ORC
Print Full Name: Bart Farmer Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate #: 991328
Email Address: bart.farm @unioncountync.gov
Signature: TA Effective Date: �4 q 2-0
"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."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Effective Date:
"I certify that I 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."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Effective Date:
"l 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."
Revised 412016