WQ0003902_ORC designation form_20210119

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATI CC)
NCAC 15A 8G .0201 AN 1 9 20ZI
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WQFiOS
Permittee Owner/Officer Name: E. Todd Clark M�QREVIE phone: [phone]
Mailing Address: PO Box 550 2$6-
City:
Newton State: NC Zip
Email Address:
Signature:
Facility Name: Clark Creek W
County: Catawba
f _ ,
Print Full Name: James Eric Jones
Certificate Type: WW Certificate Grade: IV
Certificate #: 10217
Email Address: ej nes@newtonnc. v
Effective Date:
Signature:
"I certify that 1 agrfac
ee o my designation as the Ope or in Responsibl ethorth in ISfor tAarge arge for eNCACt08Gt0204 and failing to do ed. I understand and will
pan result�n
rules and regulations ertaining to the responsibili es of the OR «s f
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Work Phone:
Print Full Name:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Effective Date:
Signature: understand and
"1 certify that I agree to my designation as a Back-up
operator of the ORC as s � forth n 1SA NCAC 08G .0204 anle Charge for the facility noted. d d failing to do so can lare abide
in
the rules and regulations pertaining to the responsibilities
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission." Y
Mail, fax or email WPCSOCC, 1618 Mail Service Center,
Fax:[phone] )=mail certadmm@ncdenr;ga
ORIGINAL to: Raleigh, NC27699-1618
Mail or Fax Asheville
a COPY to: 2090 US Hwy 70
Swannanoa, NC 28778
Fax:[phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax- 910-486-0707
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 412016

WPCSOCC Operator Designation Form (continued)
Facility Name: Clark Creek WWTP Permit #:
NCO036196
Page 2
BACKUP.ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Effective Date:
"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 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."
BACKUP:URC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Effective Date:
"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 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."
:BACKUP ®RC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Effective Date:
"1 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 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."
BACKUP ORC
Print Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature: Effective Date:
"? 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 ORC asset 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."
Revised 412016