NC0004243_Other Agency Documents_20201016

I 0 3(cyd
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIr' 1TION FORM (WPC
N CAC 15A 8G .0201 OCT 16 Z0M
Press TAB to enter information Water Quality 'Regional Operations
Permittee Owner/Officer Name: Coats North America/John Moss Aqhr%jj;j1m
wilvoV111 1 04
Email Address: [e-mail] v rNtlYfulla Uffice
Permittee Signature: Date:
Facility Name: Coa s North America Permit #
NCO004243
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: WW E
Facility Grade: III El
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Sara Lynn Hudgins Work Phone: [phone]
Certificate Type: WW E] Certificate Grade: Certificate 1009429
. . ........
Email Address: [e-mail]
Effective Date:
Signature: if 1. j
"I certify that I agree to my designation as thAperator 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.."
BACKUP ORC
Print Full Name: Phillip Charles Pittman Work Phone: [phone]
. . riTi.
CerTcate Type:
Email Address: Phillip.
Certificate Grade:
[e-mail]
El Certificate #: 996786
Signatu re: JEffective Date:
"I certify that I agree tb4 designotio"s 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 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
ORIGINAL to:
WPCSOCC.. 1618 Mail Service Center, Raleigh, NC 27699-1618
Email: [e-mail] Fax: [phone]
Mail or Fax a COPY to: Asheville Fayetteville
2090 US Hwy 70 225 Green St., Suite 714
Swannanoa, NC 28778 Fayetteville, NC 28301-5043
Fax: [phone] Fax: [phone]
Phone: [phone] Phone: [phone]
Washington
943 Washington Sq. Mail
Washington, NC 27889
Fax: [phone]
Phone.- 252-946-6481
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 Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800
Raleigh
3800 Barrett Dr,
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 5/2019

Page 2
Facility Name: Coats North America Permit #: NCO004243
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Effective Date:
"1 certify that i agree to my designation as a Backup 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 NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Central System Operators Certification Commission."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select Certificate #:
Effective Date:
"1 certify that 1 agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. l understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 080.0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission. If
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select Certificate #:
Effective Date:
"l certify that l agree to my designation as a Back-up Operator in Responsible Charge for the focility noted. 1 understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC asset 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:
Signature:
Certificate Grade: Select Certificate #:
Effective Date:
"l certify that l 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 NCAC 08G .0204 and falling to do so con result in
Disciplinary Actions by the water Pollution Control System Operators Certification Commission."
Revised 512019