NC0071242_ORC designation form_20210116

Water Pollution Control System Operator Designation Form RECE'VFQ/NCDEQ/DWR
WCSOCC
INCAC 15A 8G.0201 JAN 1 9
Permittee Owner[Officer Name.
MailingAddress:
0
City,: State: NC Zip: Phone
Email address, [e-mail]
Signature:
Date.
.......... .......... .............. ........... .................... ............................. --- ...... ........................
Facility Name: -R I �V-r �Telfx� Permit#.., Nc—cloaj aLia
Facility jyggffirade,•
Biological WWTP Surface Irrigation
Physical/Chemicaf Land Application,
Collection System
........... ...................... ............................................... ............ ........................... . I .......
Operator in Responsible Charge (O.. .........RC)
Print f-ultNarne: C "'rke,
Certfficate, Type / Grade [ Number: 4- ffigm-, WorkPhone#, (10%)
Signature: Date, I -
"t certify that I aggree, 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 15ANCAC 080,02,04 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 (RU ORC)
Print ullMarne
- 'Dannu --Hauir-
1 .1
Certificate Type [Grade [Number: WWI jL='?!N Work Phone #: ,Q J!Z 17
Signature.
Dte.-aa*
L qj -14 aw--
-1 certify, that L agree to my designation as a Back-up Operator in Responsible, Charge, for the facility noted. f understand and will abide by the
rules and regulations pertaining to the respomibilities 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 Sys
tem Operators Certification Commjssion,',
................ ...................................................................................................................................
Alail, fax or emag the WPCSOCC, 1618Mait Service, Center., Raleigh, NC27,6"-1618 Fax: 91%80-7.6492
Original to. Enmih certajftAjAQ&w0denk."%�
Nall arfax a copy tote Asheville
Fayetteville,
Mooresvift,
Raleigh
appropriam Regional,, Wee. 2Q94 US FINAry 74
225 Green St
6 10 E Center Ave,
3800 Barrett Dr
Swarmano&28779
Suite, 714
suite3at
Raleigh 276W
Fax- 82&299.7043
Fayetteville. 28301-5,043
Mooresville 281,15
Fax-, 949.571,47M
Phone. [phone]
Fax- 940-486.4707
Fax; 704.60.6040
Phoae.919J91.4200
Phone: %0.43"300
Phone. 744.663,16"
Washington
wiftaington
Winston-Salem
943 Washington Sq Mall
t27 Cardinal Dr
585 Nkaughtoxm St
XA,fashington, 27889
Wilmingtoji 28405-2845
Winston-Salem 27107
Fax: [phone]
Fax: %tO-350.2018
Fax. [phone]
Phone: 252:946.6481
Pkonez 910,7%.72tS
Phone. 33&771-SM
ReWsed 02-2013

Facility Name. Veto
- _ Permit .
Rack -Up Operator in ResponsibleChargefB ORGY .....4..a.......
Print Full Name.
Certificate T°y e I Grade ! Number.
Work Phone #. {
Date. 1'
" I cerfify, that I agree to ru}. designation a k- ug Operator in Responsible Charge: for the facility, noted. I understand €znd �uil.t abide, I+v the
rules and regulations pertaining to the responsibilities of the IIt r ORC as set forth in I5A NCAC 08G _0205 and failing to do so call result in
Disciplinary Actions by fire Dater Pollution Control System Operators Certification Cnmruission."
Back-UpTatar in Responsible Charge ORC) ......4..E.....,...,.
Print Full Name:
Certificate T _Vpe. / Grade I Number., ' : Z € rk Phone e
1
Signature: �-� �
Date- 1 � bz
"I certify that I agree to my designation as a Bach --up Operator, in Responsible Charge for the facility ranted. I understand and wit t abide by the -
rules and regulations pertaining to the responsibilities of the Btf ORC asset forth in 15A NCAC M .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission"
f, ;• a �,r. ,t, r ', �r � s : #'',_
Print Pull Name:.
Certificate Ty t` Grad N'tfmler P ;_ �" Work Pltotye Al 1 2
Signature..;
,. flare. �
°I certify that I agree to ignation as a Bach -up Operator in Responsible Charge for the facility noted. I understand and cvtll abide by the
rules and regulations pertaining to tire: responsibilities of fhe. Bt l ORC as set forth in 15A NCAC 08G 0205 and failing to do so can result. in
Disciplinary Actions by the. rater Pollution Control System Operators Certification Commission."
Print Full Name:
Certificate, Type I Grade / Number:
Signature:.
Work Phone .
late.
"I certify that I agree to my, designation as a Bach -up Operator in Responsible Charge for the facility noted. I understand and will abide Ir-vr the
rules and regulations pertaining to the responsibilities ofthe BU ORC as set forth, in t5A NCAC 080 .0205 and failing to do so can result in
Disciplinary Actions by the. water Pollution Control. System, Operators Certification Coznrnissicsr?.
Revised 02-2013