NC0049867_Back-up Operator_20210201

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
NCAC 15A SG .0201
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Facility Name: Town of Cleveland
Permit # NC0049867
Facility Type: WW Facility Grade: ll B SUBMITA SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Patrick Phifer
Email Address:
[e-mail]
Permittee Signature: Date: Oi /259/.904.Z/
Ib
ORC
Operator in Responsible Charge
Full Name: Work Phone:
Email Address -
Certificate Type. Select
Signature:
Certificate Grade: Select
Certificate #:
Effective Date:
"7 certify that l agree to my designation as the Operator in Responsible Charge for the facility noted. 1 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
Full Name:
Grant A Marrs
Work Phone: [phone]
Certificate -Type: WW Certificate Grade: I Certificate #: 1010009
Signature:
Effective Date: (0/ /� j //
no e . understand and w
certify that I a ree to my designation as a Back-up Operator in Responsible Charge for the facility t ! e ill
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
Full Name: Work Phone:
Certificate Type: Select Certificate Grade: Select
Signature:
Certificate #:
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 1.5A 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 ORIGINAL to: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 I FAX: [phone] [e-mail]
Mail or fax a COPY to: Choose DWR Regional Office that has coverage of this facility.
Revised 3/2019

Strickland, Bev
From: [e-mail]
Sent: Monday, February 1, 2021 3:47 PM
To: SVC_DENR.certadmin
Cc: Scheller, Roberto
Subject: [External] Town of Cleveland
Attachments: Backup-G Marrs-2021.pdf
Importance: High
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Please find attached an ORC form to add additional backup operator for the Town of Cleveland. This would be
in addition to Barbara Sifford.
If you have any questions, please give me a call.
Thank you,
Cathy Payne, CMC, CLGFO
Town Clerk/Finance Officer
Town of Cleveland
704-278-4777
[e-mail]
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