NC0036196_ORC Designation form_20201231

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WP�CSOET C� 2020
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: E. Todd Clark
Mailing Address: PO Box 550
City: Newton
Email Address: tcla
Signature: % / /,VW /_,/ A
Facility Name: Clark Creek
County: Catawba
PPi�!O\IJAI OFF
Phone: [phone]
State: NC Zip: 28658
Date:
Permit # NCO036196
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW
Facility Grade: IV
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: James Eric Jones Work Phone: [phone]
Certificate Type: WW
Email Address: ejones
Certificate Grade: IV Certificate #: 10217
Signature: Effective Date:
"I certify that I agree to,/ny designation as th operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the respon ibilities 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: Stacy E. Rowe Work Phone: [phone]
Certificate Type: WW
Email Address: srowe@n�,wtonnc.gov
Certificate Grade: IV
Certificate #:1009444
Signature: da Effective Dater
"/ certify that / agree to my designation 4 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."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Fax: [phone]
ORIGINAL to: Raleigh, NC 27699-1618
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: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
l rria 1, ceria lrrr jri ri denr, ou
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
L. BACKUP ORC
Print Full Name: Trevor L. Farnsworth Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate #: 1008717
Email Address: [e-mail]
Page 2
Signature: �/�;� Effective Date:
"I certify that/ 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: Lawrence Brent Townsend
Certificate Type: WW Certificate Grade: IV
Email Address: [e-mail]
Work Phone: [phone]-
Certificate #1009441
Signature: � , Effective Date:
"l certify that i agree to m� 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."
Print Full Name: Henry Anthony Hull Sr. Work Phone: [phone]
Certificate Type: WW Certificate Grade: IV Certificate #:1009442
Email Address: [e-mail]
Signature: Aj2- 11 SEffective Date:
"/ certify that / agree to my desi nation as a Back-up Operator in Responsible Charge for the facility noted. / 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."
Print Full Name:
Certificate Type: Select
Email Address:
BACKUP ORC
Work Phone:
Certificate Grade: Select Certificate#:
Signature: Effective Date:
"l certify that 1 agree to my designation as a Back-up Operator in Responsible Charge for the facility noted, l 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."
Revised 412016