NC0062383_ORC designation form_20210119

Water
Pollution ool System Operator Designation Fo r
.
NVWS
CC
NCAC 15A 8 .0201
t MOORE;
Mailing Address:
City Mate: M. zip: Phone##: flay I M9 no
Wa-
1 mail addrm: Yuri; .Konsul carolirtawaterser}dicey 3c.com
Signature: _ I U I I V r\U 11 b U I o.
-W- Date:
Facility Name: = Permit
Facilitv rade<
Biological WWI Surface Irrigation
Physical#Chernicat Land Application
Collection Systerrr
. >......................... ..>......,.,,..
Operator in Responsible Charge (011C)
Print Pull Name:
Certificate tape Grade [Number- umlaer: I i iC Work Phone 9: Li C I 1 to ZI- A . C k
Signature:; °
Date: 1
"I certify that I agree to my designation as the. Operator in Responsible Charge for the facility noted, I understand and will abide by tite rules
and regulations pertaining ttt the responsibilities of the ORC asset forth in 15A NCAC 08G ..0204 and failing to do sa can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission,-
............
.................................,.......................................
Back -Up Operator in Responsible Cie
Print Pull Name:
Certificate Type / Grade [ I4 umber: Work Phone ##: (Mg) af a
Signature. t 41
11 Date:
.'I certify that I agree to my `goation as a. Back up Operator in Responsible, Charge for the facility noted. t tmderstand and will abide by the
rules aad regulations pertaining to the responsibilities ofthe Btl ORc asset forth in l s`.ANCAC 08G ..0205 and failing to do so can result in
Disciplinary Actions by the, Water Pollution Control System Operators Certification Cornmission-"
............................ ,.....E ....... ....... ........ ......a ................. ........ ................ I .................
......
Alai[, fax or emaLt the WPCSOCC, 1618l ail Service Center, Raleigh, NC 27,694618 llKav:919.807.6492
ora lad tom- Dig: ee a ttti tiir s
Mail arfax a copy to the Asheville Fayetteville N ooresville Raleigh
appropriate Regional €ffl-re. 2090 US Elwvyr 70 225 Green St 6I0 E Center Ave 3800 Barrett Dr
Swannanoa28778 Suite'714 Suite3GI Raleigh 27609
Fax: 828.2 70Fayetteville 29301-5043 Moocesuille.2al l5 lax: 91 .52t. 18
Phone: 829.296ASW Fax: %10.486,0747 Fax: 704.66 ftc e: l .7%L4200
Phone: 9I11:433.334* Phone, 7K663.1,699
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone. [phone]
Wilmington
127 Cardinal Dr
Wilmington 284€ 5-28,15
Fax, 910350a2018
Phone. 9lk79 '7215
Winston-Salem
585 4k4ughtutvtt St
Winston-Salem 27107,
Fax* 316.771.4631
Phone: [phone]N,
J A N I a 2Or; L'1
Devised02-2013
f
f a

Facility.Name:LO&N( Permit R=U
Back -Up Operator in Responsible Charge (BU C:) t ..� .a�...d.. _
Print Full Name. bi b ell t4,1,41 �
Certificate Type I Grade # Number: � Murk Phone #€:
Date-
"t certify that I agree to my designation: ack-up Operator in Responsible Charge for the racility, 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 railing to do so can result in
Disciplinary Actions by the; Water Pollution Control System Oper tors Certif'cation Coecnmission "
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: -
Certificate TV Grade # Number: Work Phone##. (Vo I,ZLf�—
INDIO
"I eertif 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 NCAtw 08G _.0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission"
Back -Up Operator tat Responsible Charge (BU ORC)
Print Full Name. -
Certificate Type t Grade f lu�tber: � � Work Phone M � `�� � � q 3
Signature: Date,
1 certify that I agr my designation as a Back-up Operator in Responsible Charge, for the the lity noted 1 understand and will obi Izy the;
mIcs and regulations pertaining to the responsibilities of the BIT ORC asset forth in l5A 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 itt Responsible Charge (BU O
Print Full Name:
Certificate. cat Type I Grade # Dumber:
Signature::
Work Phone ##.
Dates
`=I certify that I agree to my designation as a Back-up Operator in Responsible: Charge for the facility noted, I understand arid: evil l abide by the
rules and regulations pertaining to the responsibilities of the BU ORC asset forth in 15A NCAC 08G .0205 and failing to dose can result in
Disciplinary= Actions by the Water Pollution Control System Operators Certification Commission,"
Revised 02-201