NC0071242_ORC designation form_20200928

Water Pollution Control System Operator Designa
fia� Form'
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Cerfificate Type/ Grade / Number:
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v _ _ -tom s, ef the ORC as sa funh in IS
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-a -W Openaar im Responsible chargef avid. I uaderstmd and will abide by the
sf es and par-aink-Mdie F sa off BU €SRC as set forth ra 15A NCAC4 �005 and f € �€r cam€ �a
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17 �j Dr
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Facility Name. GWt ] 1-Vmw C00 C Permit N.-
Print, Full, Name-:
Certificate Type I Grade tNtmiber-. WorkPItoneg- (1j
Date:
/Z 7/2
"F certif that f agree to my atiork as a Back-up Operator in Responsible, Charge fear the facility rrote& I understand arid will, abide. by the
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rules and regutatiens pertaining to the responsibilities of the BU, ORC as set forth in I SA NCAC OS G -0205 and fading ter do, so can result in
Disciplinary Actions by the Wafer Pollution Control System Operators Certification Commissibe
Hack -Up, Operator in Responsible Charge (HU ORC)
Print Futt Name:
Certificate Type I Grade I Number-,
Signature:
Work Phone A:
Date:
-1 mortify that V a gree to mydesignation as a Back-up Operator in Responsible Charge for the facility note& [ understand and will abide ky the
rules and regulations pertaining to the responsibilities of the BU ORIC as set forth in t5ANICAC OS G .02GS and failing to do so can result in
Disciplinary Actions by the Water Pollution Centro) Sxsteni Operators Ciertilfwation, Corrinthision-'
............ ...................... ............ -.- ........................... ..... ....... .............
Back -Up Operator in Responsible Charge (DU ORC)
Print Cull Name:
Certificate Type / Grade I Number:
Signature --
Work Phone #:
Date:
I cuW that f agree to, m3,., designation as a. Back-up Operator in Resensible Charge fiar the facility noted- L understand and, will abide Ray, the
mks and regulations pertaining to the responsibilities If the, BU ORC as seat fih in I SA NCAC Oki 02G5 and failing to do so can result in
Disciplinary Actions ky the Water pollution, Control System OperWbrs Certification Corrm-dssiom'
................................ --1--- ............. -.- ..........
Back -Up Operator in Responsible Charge (BU ORC)
Print Fa Name -
Certificate Type / Grade / Number -
Signature:
Work. Phone #: ( I
Date,
-f certify that I agree to my designation as a Back-up Opefair in R,,-�Wnsibte Cbarg-- for the facility, noted- I understand mid will, abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in t 5AE\'C-NC 08G A20655 and failing to do so, can r--ulf, in
Disciplinary Actions by the Water Pollution Control System Operators Certification COmmissicu.7
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Revised G22013