NC0089052_Other Agency Documents_20201110

Water Pollution Control System Operator Deslgnagw' NC �al Qu of
WPCSOCC Received
NCAC 15A 8G .0201
Permittee Owner/Officer Name:
NOV 0 6 2020
Mailing Address:_ 367) R,'sga/t Covared Qrid�p n,/ Regional Office
City: _h5,4 40ra State: Ale Zip: 272 OF -
Email
Signature:
Phone #: 336- `JS3 —3'1S0
Date: 19 _6 ` _0967Z
Facility Name: 2Zoo1and RV /a.-k LLC Permit#: Me ooif4o3'a
County: an p�aLt
.................................................................................................................................................
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
iological Collection Physical/Chemical Surface Irrigation Land Application
................................................................................................................................................
Operator in Responsible Charge (ORC)
Print Full Name: hk;e4,PIN- Ho(v4rJADim& Email: PA6W¢r.1_f A' Azar-7,57t./ie7
Certificate Zjzay�Oti
Grade / Number: /W/(�� y a 753,3/n Work Phone #: 33, —1705-- /'711X
Signature: 12-6 -'azo
"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 (B//U/� ORC) / �'r�.
Print Full Name: &14it P.'fi�% (J4tYd/S Email: pig 6/9X. / 0j;?%_St..}
4 L F , f%:"
Certificate Type / Grade / Number: Wkl'Y J S S 3 9 Work Phone #: 336 — 56/-- W 78
Signature: Date: /o"O,?o
" 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, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to: Email: certadmin@ncdenr:gov
Mail or fax a copy to the Asheville
Favetteville
Mooresville
Raleigh
appropriate Regional Office: 2090 US Hwy 70
225 Green St
610 E Center Ave
3800 Barrett Dr
Swannanoa 28778
Suite 714
Suite 301
Raleigh 27609
Fax: [phone]
Fayetteville 28301-5043
Mooresville 28115
Fax: 919571A718
Phone:[phone]
Fax:910A86.0707
Fax:[phone]
Phone:919.791A200
Phone:[phone]
Phone:[phone]"
Washington
Wilmington
Winston-Salem
943 Washington Sq Mall
127 Cardinal Dr
450 W. Hanes Mall Rd
Washington 27889
Wilmington 28405-2845
Winston-Salem 27105
Fax:[phone]
Fax:[phone]
Fax:[phone]
Phone:[phone]
Phone:[phone]
Phone:[phone]
Revised 05-2015

Date: V- 287 - X
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Delegation of Signature Authority
Zooland RV Park, LLC
NPDES Permit Number NCO089052
To Whom It May Concern:
By notice of this letter, I hereby delegate signatory authority to each of the following individuals for all
permit applications, discharge monitoring reports, and other information' relating to the operations at
the subject facility as required by all applicable federal, state, and local environmental agencies
specifically with the requirements for signatory authority as specified in 15A NCAC 2B.0506.
Individual #1 Individual #2 (ifapplicabie)
If you have any questions regarding this letter, please feel free to contact me at Enter Email or Phone
Number.
Sincerely,
Authorized Signing Official's Signature:
Authorized Signing Official's Title: _Owner
Mailing Address: 3671 Pisgah Covered Bridge Rd. Asheboro, NC 27205
Email Address: [e-mail]
Office Phone:[phone]
Mobile Phone:[phone]
cc: Win> on Sala„ Regional Office, Water Quality Permitting Section