NC0085812_ORC designation form_20200506

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
Permittee Owner/Officer Name:
NCAC 15A 8G .0201
Press TAB to enter information
Union County Public Works / Bart Farmer
Mailing Address: 4600 Goldmine Rd
City: Monroe
Email Address: [e-mail]
Signature:
Facility Name: Grassy Branch WWTP
County: Union
State: NC
Phone: [phone]
Zip: 28112
Date:
Permit # NCO085812
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 Certificate #: 1005930
Email Address: [e-mail]
Signature: Effective Date: C/CP8 o4L--"
"1 certify that 1 agree to my designation as the 0 ator 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: Jon Page Work Phone: [phone]
Certificate Type: WW
Certificate Grade: IV
Email Address: [e-mail]
Certificate #: 9998
Signature: Effective Date: Vcj-/,2
"/ certify that I agree to my designat n as a Back-up Operator in Responsible Charge for the facility noted. / 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) Page 2
Facility Name: Olde Sycamore WWTP Permit #: WQ0011928
BACKUP ORC
Print Full Name: Rick Mareth Work Phone: [phone]
Certificate Type: WW
Certificate Grade: I
Email Address: [e-mail]
Signature:
Certificate #:1008059
Effective Date: �-a$-aD
"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: Bart Farmer Work Phone: [phone]
Certificate Type: WW
Certificate Grade: IV
Email Address: [e-mail]
Certificate #: 991328
Signature: Effective Date:
'l20
"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."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Certificate Grade: Select Certificate M
Signature: Effective Date:
"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."
Print Full Name:
Certificate Type: Select
Email Address:
BACKUP ORC
Certificate Grade: Select
Work Phone:
Certificate #:
Signature: 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."
Revised 412016