830008_Operator Designation Form_202000924

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NCAC 15A 8P.0201
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: ti} 'Operator In Charge(OIC)
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"1 certify Mat 1ate: J-2.q 2.4)
COro my designation as the Operator in Chc ro:the facility waled 1 understand and
Pc--csutieg to the responsibilities set forth in 15A NCAC O8F.O2 C3 a:td failing to do so c
Pollution Cotmol System wdt abide by the n ies *.t
,. Operators Certification Cocttratssior.' an suit in D' teguhttioos
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Back-up Operator to Charge(Sack-up 01C) (OD!iona0
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Signature:e: Work?hone'(-w=.�_
1 certify that 1 agree. to my dsignahor.as 9a4-
op';�, rcgnlations penainiag to the rmponsihilities set;forth in SA~NCR Der.0203 facility noted.I and al will chicly by fact-Wes and
Water Pollution Control Sy re Operators Certification Comic.c'o•. fatIing to do so cue result in 7iscipiinary Ado-as by the
OwneePermittee Name: 'reel. L,• fti(4.12,Thrt
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Arat4 far or email the WPCSOCC, I618.Wail se 7 ice Center, Raleigh,NC 27649-16I8 Fax:[phone]
original m: Etna:eertadmin(')a nedenr.„ov
Mail or fax a copy to the Asheville r ayetreville
' aPPreP Regional Olga: 2090 US lin 70 225
Green St Mooresville 0 cater Ave
Swannanoa28778 Su:tc714 3<d�301 Italei380DBamettl}r
Fax:[phone] Fr:y acille 28301-5043 Moosetrraie 23115 �274509
w.. Phone:[phone]a00 Fa:::910 486.0707 gam;7b 3 0 8as:�9.571AT18
;�, •gs Put:910 433.3300 Phone' Phoaes929.T91�t200
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4.663.1699
sue ' t Washington Wilmington Winston-Warn
943 Washington 3q Mall 127 Cardinal Dr 450 W.Hanes Mall Rd
Washington 27889 Wilmington 28405.2845 Winston-Salem 27105
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(Retain a cop,'rii'tMsj0t:7tfor oitr•records)
1tcwaed 05-2015
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