NCG500323_Regional Office Historical File Pre 2018 (55)

VShurtape
02 February 2009
WPCSOCC
1618 Mail Service Center
Raleigh, NC 27699-1618
Subject: NPDES Permit No. NCO072664
ORC / Back -Up ORC Designation Form
Shurtape Technologies, LLC. - Stony Point Plant
Alexander County
RECF�VFD
F E B - 5 2009
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Please find attached an updated ORC Designation for the subject facility. Should you have any
questions or concerns; please contact me at [phone] or via email at [e-mail].
Respectfully yours,
Mark E. Hawes, P.E.
Director of Environment & Safety
Enclosures
cc: Wes Bell, w/ enclosures
David Neff, w/ enclosures
Matt Moore, w/ enclosures
Jeff Roseberry, w/ enclosures
Shurtape Technologies, LLC PO Box 1630 Hickory, NC 28603 www.shurtape.com

Water -Poll ution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name: Shurtape Technologies, LLC / David Neff, Plant Manager
Mailing Address: P.O. Box 48 / 8510 NC Highway 90 East
City:St°ny P8t State: NC Zip: 28678 _ Phone #: (8 5) 325•538
Facility Name: Shurtape Technologies, LLC - Stony Point Facility
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM!
Facility Type & Grade:
Date: / O
Permit #: NCO072664
County: Alexander
Type Grade Type Grade
Biological WWTP X 11 Surface Irrigation N/A
Physical/Chemical /� Land Application N/A
Collection System 14A
Operator in Responsible Charge (ORC)
Print Full Name: ,Jeff
Certificate Type / Grade / Nu ber: Biological WPC, Gil, 991099 Work Phone #: , 704) 555.65_
j ,
Signature: Aaji, Date:_ %_J a1O7
"I certify that I adr,e 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 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."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Doug Hall
Biological WPC Gil, 991096 4704)
828) 322.T1'00_
Certificate pe Grade Number: g Work Phone #: [phone]
Signature: 0'' Date: / .7®O g
I
"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."
...........................................................................................................,.....................................
Mail or Fax to: WPCSOCC
1618 Mail Service Center
Raleigh, NC 27699-1618
Fax: [phone]
(See next page for designation of additional back-up operators. Designation of more than one back-up operator is optional.)
Revised 8-2007

Additional Back-up ORC designations
Facility Name: S�Gti/-77 4� �e�/l�r� ez, �_! % xY rl"el � r' Permit #: ! `� �- oc>7W �
..................... :........................................................................................................................
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: / ,Q_AC/1 r C D eJ I-11 L_5 2/anl AI (9 n!
Certificate Type / Grade / Number: l �tl� Work Phone #: o0y
Signature: ���� Date: 6 Z C) 62
"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."
Operator in Responsible Charge (BU ORC)
Print
Certificate TvvKGrade / Number:
Signature:
Work Phone #:
Date:
"I certify that I agree to my design o a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by
the rules and regulations pertaining t esponsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can
result in Disciplinary Actions by the Wa lti
on Control System Operators Certification Commission."
...............................................,............... .........................................................................
Back -Up Operator in Responsible Chaite:AU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Work Phone #:
"I certify that I agree to my designation as a Back-up Operator in Responsible C. ge for the facility noted. I understand and will ,abide by
the rules and regulations pertaining to the responsibilities of the BU ORC as set fort'n 15A NCAC 08G .0205 and failing to do so can
result in Disciplinary Actions by the Water Pollution Control System Operators Certific ion Commission."
..............................................................................................14............................... ........
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number:
Signature:
Work Phone #:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and wifNbide 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
result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 8-2007