NC0069841_ORC designation form_20200506

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Union County Public Works I Bart Farmer phone: [phone]
Permittee Owner/Officer Name 4 300 Goldmine Rd Zip: 28112
Mailing Address: State. NC
City: Monroe
Email Address: bart•[e-mail]
Date:
Signature:
Permit # NCO_ 0�41
Facility Name: Crooked Creek WWTP
County:
Union
EACH TYPE AND CLASSIFICATION OF SYSTEM:
YOU MUST SUBMIT A SEPARATE ARATE FORM FOR _®
Facili� pe� �
Farility Grade: 111
OPERA7uM 1"m T`
SAMUEL A. LAYTHAM
Print Full Name: Certificate Grade: IV
Work Phone: [phone]
Certificate #: 1005930
Certificate Type: unioncountync.gov
Email Address: alex.laytham@ Effective Date:
Charge for the facility noted. I understand and will abide by the
Signature: for in Responsible to do so can result in.
that I agree to my designation as the the ORC as set forth in 15A NCAC 08G .0204 and
1 certify t pertaining to the responsibilities of
rules and regulations p operators Certification Commission."
Disciplinary Actions by the Water Pollution Control System
BACKUP ORC 704-534-2143
Work Phone:
Jon Page Certificate #: 9998
Print Full Name: Certificate Grade: 1V
Certificate Type:
[e-mail]
Email Address: 1 Effective Date: dY � ._-------
will
nature: or the facility noted. I u failing
'' n t to dad canpesultbide bn
Sig operator in Responsible Charge f
that 1 agree to my designa ion as a Back-up p the ORC as set forth in 15A NCAC 08G .0204 and f 9
"1 certify pertaining to the responsibilities of
the rules and regulations p operators; Certification Commission." Finad, [e-mail]
Disciplinary Actions by the Water Pollution Control System Op Fax: [phone]
S -Ice Center,
Mail, fax or email
ORIG L to:
WPCSOCC,1618 Mail e
Raleigh, NC 27699-1618
Asheville
Mail or Fax 2090 US Hwy 70
a COPY to:
—' Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington Mall
943 Washington Sq.
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax- 910-486-0707
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 412ol6

Page 2
on Form (continued)
WpCSOCC Operator Designati
Permit #: NCO069841
i Name; Crooked Creek(rP
FaCii ty
BACKUP CRC 704-296-4227
Work Phone:
`
Certificate #:991328
Print Full Name: Bart Farmer Certificate Grade: N
Certificate Type f [e-mail] Effective Date:
U�g��
Email Address: �1 �� or, the facility noted. I understand and will abide by
onsible Charge f NCAC 08G .0204 and failing to do so can result in
Signature: 0 erator in Resp orth in 15A
that I agree to my designation ih a Back-up p the ORC as set f
"I certify to the responsibilities of
regulations pertaining operators Certification Commission.
the rules and reg the Water Pollution Control System
Disciplinary Actions by
BACKUP ()RC Work Phone:
Certificate #:
Certificate Grade: Select
Print Full Name:
Certificate Type: Select ._--
Effective Date:
Email Address: or the facility noted. I understand and will abide by
onsible Charge f ailing to do so can result in
Signature: O erator in Resp orth in 15A NCAC 08G .0204 aridfailing
agree to my designation as a Back-up p the OR as set f
"I certify that i to the responsibilities of
ulations pertaining stem Operators Certification Commission.'
the rules and reg the water Pollution Control Sy
Disciplinary Actions by
BACK ®RC Work phone:
print Full Name: Certificate
Certificate Grade:
Select #:
Certificate Type --
Effective Date:and
Email Address: facility noted. I understand and will abide by
onsible Charge for the f ailing to do so can result in
Signature:
operator in Resp fort on
in 15A NCAC DSG .0204 andfailing
designation as a Back-up the ORC as set f
"I certify that I agree to my deli not o the responsibilities of nation Commission."
ulations p 0 erators Certif'
the rules and reg the water Pollution Control system P
Disciplinary Actions by
BACKUP ORC Work Phone:_______------"--
Print Full Name: Certificate Grade:
Select Certificate #:
Certificate Typ e. :. Select Effective Date:
Email Address: or the facility noted. I understand and will abide by
Responsible Charge f note and failing
to do so can result in
Signature: opera in Resp forth in 15A NCAC 08G
that I agree to my designation as a Back-up p the ORC as set f
"I certify to the responsibilities of Revised 41201E
regulations pertaining stem Operators Certification Commission.
the rules and the Water Pollution Control Sy
Disciplinary Actions by