NC0062383_ORC designation form_20200928

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Print Prat lame: Ima' 4 � -
Certificate T�vpe I Grate /tint er- � � Wnrk P tine- €
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Signature: L Date: —
certify that I a
gree to my desigrtatiott as a Back-up Operator Responsible the facility notecL I understand atwill abide by the
mils and regulations pertaining to the resonsibilities of the B , ORC as set fQrdi in 15NCAC QiG _ 2G5 and Wing in Pict se can result i
DisciplinaryActions by the eater Pollution Control System Operators, Certification Cottunission."
Back -Up Operator in Responsible Charge
Print P'ttlt Name-,
Certificate Type / Grave I zumher:
itttre:
Work Phone
`'i certky that C agree to ni designation as a Back-up Operator nt Responsible Charge for the fay: ifity noted- I understand and wilt abide try= the
roles and regulations pertainke to the responsibilities of the Bti GIRG as set forth in 1,5 -,\CkC 094 a _ff2€t5 and fail i g to do, so can result in
Disciplinar,�Actibns by the rater Pollution Control System Operators Certification Gatnttnissia —
tie stoic in Responsible G arW BU R
Print FuU Barrie:
t ertiftcate "C�-pe / Grade / Number
Signature.
Work Phone 4�. f
H
T cerW that I agree to my dzsigoatibn as a Back-up Operator in Responsible Charge for the facility noted I understand and wat abide: by the
rufc4s ad re4trladous penainiirg to the responsibilities of the BU € RC as set forth in 15 O O 6G M-05 and failing to, do so cart result in,
Disciplinary,Actions by the Water Pollution Control I -stern Operators Certification Oor issiou-''
Rack -Up Operator in Responsible, G R
Print Mitt Name:
Certificate Type I Grade / f weber-
Fpaturm,
Work Phone : C I
Date:
"T ccrtif� that f agree to m),, desig ttian as a Back-up Opera r in responsible Charge for the fitcility noted- I understand and teitt abide by the
rules and regulations pertaining to the responsibilities of the BJ ORC as set forth in 15A NCAC GSG _tit 5 and tailing to de so can, result ill
Disciplinary fictions by the, Water Pollution Control S�-stera Operators Canilication Cords-sion '
Revised tl €f13