NC0072664_Regional Office Historical File Pre 2018 (45)

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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
Hickory
City:
State: NC
Email addr [e-mail]
Zip: 28603
WQP,OS .
Phone #k, [phone]
Signaturb;��( J� Date: /Z���.�
................................................................................................................................................. .
Facility Name:
Shurtape Technologies, LLC - Stony Point Plant Permit #: NC0072664
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Tvoe/Grade:
Biological WWTP Grade II Surface Irrigation
Physical/Chemical Land Application
Collection System
OFFICE
............................................................................................................................................... ,
Operator in Responsible Charge (ORC)
Print Full Name: Douglas Ray Hall
VW1/-3/996520 1 [phone]
Certificate e / Gra e /Number: Work Phone #:
Signature. Gt.� �', Date:
N
"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
WW-1/-1002498 1 [phone]
Certificate Ty e / Trade / Nu per: Work Phone #: +)
Signature. �'� Date: /2 .l�' UPS
"I certify that I agree to my designation as a Back-upwerator 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 to can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
......................................................................
Mail, fdx or email the WPCSOCC; 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Email _certadmn(a�ncdenr gov
Mail or. fax a copy to the Asheville
appropriate Regional Office: 2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
Mooresville
Raleigh
225: Green St
610 E Center Ave :
3800 Barrett Dr.
Suite 714
Suite 301
Raleigh 27609.
Fayetteville 28301-5043
Mooresville 28115
Fax: [phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Wilmington
Winston-Salem
127 Cardinal Dr
585 Waughtown St
Wilmington 28405-2845
Winston-Salem 27107
Fax: [phone]
Fax, 336.771.4631
Phone:[phone]
Phone:[phone]
Revised 03-2014

Facility Name: Shurtape Technologies, LLC.- Stony Point Plant Permit #: NCO072664
...... ...........................................................................................................................................1.
erator in Responsible Charge (BU ORC)
Back -Up Op
Travis Edwih-Brannon
Print Full Name:
WW-3/ 990808 p
Certificate Type / Grade / Number: Work Phone #: (� Z� 2 2 D
rJ
Signature:
-----=/%v'-C , l.-�� ,�---- 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 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 #: ( 1
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 .020:5) 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:
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 result in
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:
"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
DisciplinaryActions by the Water Pollution Control System Operators Certification Commission."
Revised 03-2014