NC0060755_ORC designation form_20210119

Water Pollution Control System Operator Designation Form AFCEIvr=D/NCDEQ/DWR
wmsoc_c J A N T
NCAC 15A 8G.0201
Permittee Owiter/Officer Name: WQROS
PA0089VU"EGIONAL OFFICE
Mailing Address: 3a 1 to
City. Cho_VW6 State: Zip: _6122-11— Phone 4:(16q, )_3
Email adds
Signawre.
.............. ....................... I .............................. ............................. .......... .................... __.
Facility Name-t Permitk NCOMR61155
Facility IW&Grade:
Biological WWTP Surface Irrigation
Physical/Chemical Laud Application
Collection System
...................... ........... ........ ............................................................ I—— ........................
Operator in Responsible Charge (ORC)
Print Full Namel., 14 n w1ja P)
Certificate Type/ Grade /' Number: W
U—R Work Phone #: a U)-!2!!j 1
I certify that I agree to my designation as thgerator is ResponsibleChargefor the facility noted. f understand and Ivi I I abide by the rules
and regulations pertaining to the responsibilities of the ORC asset forth in 15A NCAC 08G .0204 and failing to der so can result in Disc ip han-
n -
Actions by the Water Pollution Control S-yystcm. Operators Certification Commission.-
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Back -Up Operator in Responsible Charge (BU ORC)
Print FLdlName: TkMINU "1811 6-
Certificate Type / Grade / Number: Work Phone. #:
Signature: Date.
'T certif. that f agree to agree de1jg.,knafion as a Back-up Operator in Responsible. Charge for the faeffiq,7 noted. I understand andwilt abide, by the
rules and regulations pertaining to the responsibilities of theBUORCassetforftin 15ANCAC08G.0205, and failing to dosocan resultinDisciptinary Actions by the Water Pollution Control System Operators Certification Commission.'
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Afail, fax or emait the WPCSOCC, 1618 Mail Service, Center, Raleigh, NC27699�461....
8 Fax:[phone],2
original to. En"Veem
Mail arfax a copy to the Asheville
Fayetteville
Mooresville,
Raleigh
appropriate Regional Office.- 2090 US ffivy- 7 0
225 Green St
610 E Center five
3800 Barrett Dr
Swannanoa28778
Suite 714
Suite301
Raleigh 27604
Fax-, 828.299.7043
Fqe4eville; 2830-1-5043
Mooresville, 2-8115
Fax, %91571.4719
Phone: [phone]M
Fax: 91(W86.0707
Fax-, 704.663.6M
PhoRe:919.W1.42W,
Phone. 94W3.3300
Phone: 7KWjW%
Washington
Wilmington
Winston-Salem
943 Washington Sq Mail
127 Cardinal Dr
585 Waughto�m St
Washington 27889
Wilmington 284052845
Winston-Salem 27107
Fax: [phone]
Fax: 910,35t}2018
F= 33V71,4631
Phone: 252.946.648t
Phonez 910.796.7215
Phone: [phone]M
Revised 02-2013

Facility Name: PermiM
............... .............................. .................... ..................................... ...................
Back -UP Operator in Responsible Charge (RU ORC)
Print Full Name. -
Certificate Type[ Grade / Nurnber:__!3:Ao.,'-.4,,,kz ic_Q=4_11X'2 WorPhone At: (SS01, 2t.,!u. e-,. 4'os�
Signature,
Date: oz z--.
"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 ky, the
rules and regulations pertaining to the responsibilities ofthe, BU ORC as set forth in t5A NCAC 08G.0205 and faitingto do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
....................... .... w ..................................................................................... . ................... I .......
Back -Up Operator in Responsible Charge (BU OR
Print Full Name:
Certificate Type. I Grade I Number: J)'5 Work PhoneA ('I_V;1 IV) 60
3 e i
Signature.- Date: I? Zz
"I certify, that I agree to thy desiation as a Back-up Operator in Responsible Charge for the lacililynote& I understand and uqjl abide, by the
rules and regulations pertaining to die responsibilities of the BU ORC! asset forth in 15A NCAC 08G .0205 and Wiling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission-"
......................................................................... I .......................................................... .........
Back -Up Operator in Responsible Charge (BU ORC)
Irl I -
Print Full Name: 1.­� nc=f 3-
Certificate Type/ Grade/ Number:,. t'Wark
Signature: 1011- CU
'I cerftl�- that L 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 08(i,0205 and failing to do so, can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commissim.,
.................. ................................................................................................... I ......................
Back -Up Operator in Responsible Charge.(BItf OR..
Print Full Name:
Certificate Type I Grade / Number Work Phone if:
Signature:
Date:
"T certify that I agree to my designation as a Back-up Operator in Responsible Charge;de -b
for the facility noted tun ratundandxiltabid, y the
rules and regulations pertaining to the responsibilities ofthe BU ORC as set forth in 15A NCAC ()8G,0205 and foiling to do so can result in
DiwiplinaW Actions by the Water Pollution Control System Operators Certification Commission.-
............. ......................................................................... - ......... — .. ... 1­1 ............................ I ............. ......
Revised 02-2013