WQ0001817_Water Pollution Control System Operator Designation Form_20200702

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WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WFCC )
Permittee Owner/Officer Name:
Email Address:
Permittee Signature:
Facility Narne.
Albemarle Utility Company
NCAC 15A 8G .0201
Press TAB to enter information
Permit #
JL/C 7 2020
W00001817
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: SI Q
Print Full Name:
Certificate Type:
Email Address:
Facility Grade: Select
ORC - OPERATOR iN RESPONSIBLE CHARGE
Danny Shelton Perry Work Phone: [phone]
Si Q Certificate Grade: Select Certificate #: 1005111
dannv.Derrvaalbemarleplentatbon.com _
Signature: U Effective Date:- �ca�emfa
"l certify that t agree to my desf tion as the Operator in Resp sible Charge far the facility noted. f understand and willabide 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
Discipiinory Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: James Nickolas Bland Work Phone:[phone]
_
certificate Type: Si Q Certificate Grade: Select Certificate #: 1007997
Email Address:
Signature: �� Effective Date: J 4 n K
't certify that 1 agree o my designation as o Bltck-uv Operator in Responsible Charge for the facility noted. !understand and w1/1 abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 086.0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email WPCSOCC,161S Mall Service Center, Raleigh, NC 27699-1618
ORIGINAL to: Ena1t: cerfiadrnistiricdenr.gAni Fax: [phone]
Mail or Fax a COPY to: Asheifitle Fayetteville
2090 US Hwy 70 22S Green St., Suite 714
Swannanoa, NC 28778 Fayetteville, NC 28301-5043
Faw 828-299-7043 Fax: [phone]
Phone- 828-296-45 00 Phone: [phone]
Washington
943 Washington Sy. Mail
Washington, NC 27889
Fax: [phone]S
P4wge: 252-946-6481
Wilmington
127 Cardinal Dr.
Wilmington, NC 2MS-2845
Fax:[phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone: [phone]
Vlll"ston-salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-77"8W
Ralekh
38M Barrett Dr.
Raleigh, NC Z7609
F2X: 919-571-4718
Phone: [phone]
ReVhWd &2M-q

Page 2
Facility Name: Albemarle Utility Company Permit##: W00001817
BACKUP ORC
Print Full Name: Wiiiio-Anderson Morgan Jr Work Phone:[phone]
Certificate Type: Sl ED Certificate Grade: Select Certificate #:998794
Email Address: ftj cj , C,0^x
Signature: Effective Date: '74
"1 certify that 1 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 Certiftation Commission."
BACKUP ORC
Print Full Name: Work Phone:_ _
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
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 25.4 NCAC 08G .0.204 and failing to do so can result in
DIsaplinoryActions by the Water Pollution Control System Operators certification Commission."
Print Full Name:
Certificate Type: Select
Email Address:
BACKUP ORC
Work Phone:
Certificate Grade: Select Certificate #:
Signature: Effective Date:
"1 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 NC4C 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators 4rertrf7cotion Commission."
BACKUP ORC
Print Full Name: Work Phone:_
Certificate Type: Select Certificate Gracie: Select Certificate #:
Email Address:
Signature: Effective Date: -
"I certify that 1 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 NC4C 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 5=9