NCG500323_Regional Office Historical File Pre 2018 (44)

RECEIVEDlNCDENR/DWR
22 December 2015 DEC 2 8 201
WQROS
Via Certified Mail, Return Receipt Requested MOORESVILLE REGIONAL OFFICE
7012 0476 0002:1700 5781
WPCSOCC
1618 Mail Service Center
Raleigh, NC 2769971618
Subject: NPDES Permit No. NCO072664
ORC / Back -Up ORC Designation Form
Shurtape Technologies; LLC - Stony Point Plant
Alexander County
Please find attached updated ORC Designation Form for the subject facility. The updated
information reflects a change in the backup ORC designations for the facility.
Should you have any questions, please contact me at [phone] or via email at
le 1p in(a-),shurtape.com.
Respectfiillyyours,
Jerry W. Eplin, PE
Environmental Manager
Enclosures
cc: MRO; 610E Center Ave, Suite 301, Mooresville; NC 28115
David Neff
Doug Hall
Jerry Ephn
Shurtape Technologies, LLC
P.O. Box 1530, Hickory, NO 28603 • Phone: [phone] • Toll -Free: 888.442.8273

A Vll Ll L1V11 ,<.V11L1 Vl k3jaLGlll •V•1JGl aLVl " U.51g11[ILIVII 1' VI -Ill.
WPCSOCC.
NCAC_15A 8G .0201 : RECEIVED/NCDENR/DWR
Permittee Owner/Officer Name: Shurtape Technologies, LLC /.David Neff, Plant Manager DEC 2 8 2015
Mailing Address: P.O. Box 1530
City: Hickory State: NC
Email addre�[e-mail]
Zi28603
p:
WQROS .
1v11_;U1C0V ILLC•I
Phone # _(_____+- [phone]
OFFICE
Signatur� Date: Cz�/fr
Facility Name: :Shurtape Technologies, LLC - Stony Point Plant NC0072664
Permit #: .
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Tyne/Grade:
Biological WWTP Grade II Surface Irrigation.
Physical/Chemical Land Application
Collection System
Operator in Responsible Charge (ORC)
Print Full Name:
Dougias Ray Hall
WW-3/996520 1 [phone]
Certificate e / Gra e /.Number: Work Phone #: (l
Signature: Date:
"I certify that I agree to my designation as the 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."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Timothy Scott Carrigan
i ..
WW-1/ 1002498 1 [phone]
Certificate Tye de / Nu er: Work Phone #: (_ _.
Signature. Date: /o2 5
"I certify that I agree. to my designation as a Back-up erator in Resporisible Charge for the facility noted. I understand and will:'
bide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth -in 15A NCAC 08G .0205 and failing to do sb-can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
............................................................
Mail, fax or entail the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 276994618 Fax: [phone]
original to: Em"ail: certadmin nedenr: oY _
Mail or. fax d copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office:: 2090 .US Hwy 70 225. Green St 610E Center Ave ... 3800 BarrettDr
Swannanoa 28778 ' Suite 714 Suite 301 Raleigh 27609
Fax: [phone] Fayetteville 28301-5043 Mooresville 28115 Fax: [phone]
Phone:[phone] Fax:[phone] Fax:[phone] Phone:[phone].
Phone:[phone] Phone:[phone]
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 585 Waughtown St
Washington 27889 Wilmington 28405-2845 Winston-Salem 27107
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone] Phone:[phone] Phone:[phone]
1
Revised 03-2014

Shurtape Technologies, LLC -.Stony Point Plant NCO072664
Facility Name: Permit #:
Back -Up Operator.in Responsible Charge (BU ORC)
Travis Edwin Brannon.
Print Full Name:
WW-3/ 990808
Certificate Type / Grade / Number: Work Phone #: (� 2� 3 2? " 2 7 P D
Signature: /`��.�_— ... 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 BU ORC as set.forth in 15A NCAC.08G .0205 and failing to do so can result in
Disciplinary Actions by Water.Pollution Control System Operators Certification Commission."
Back -Up Operator in. Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade % Number: Work Phone #:
Signature: —
::.Harp•
":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 BU ORC as set forth in 15A NCAC 08G .020 and failing -:to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certificatior .Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number: Work Phone #: ( )
Signature: 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 BU ORC as set forth in :15A NCAC 08G .0205 and failing to do so can resultin.
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission." -
........ _.. ..
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number: Work Phone #: ( )
.Signature: 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 BU ORC as set forth in I5A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 03-2014