NC0026352_Operator Designation Form_20140121

01/27/2014 08:22 9108633738
TOWN OF BLADENBORO
PAGE 02/02
Water Pollution Control System Operator Designation Form.
WPCSOCC
NCAC 15A SG .0201
Permittee Owner/Officer Name:
Mailing Address:
PO BOX 455
TOWN OF BLADENBORO •
RUFUS DUCKWORTH, MAYOR
City: BLADENBORO,
State: NC ,Zip: 28320
Email address: „[e-mail]
Signature:
Pzr
Phone #: [phone]
Date: 01/21/2014
Facility Name:
TOWN Ok' BLADENBORO Permit #: WC0026352
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Gracie:
Biological WWTP
Physical/Chetnical
Collection System
•
II
Surface Irrigation
Land Application
N/A
N/A
Operator hi Responsible Charge (ORC)
Print Full Name: ,r, • ALTON. LYNN BRISSON
Certificate 'Type
Signature:
rade /.1`tu�419z , wt4 13484` Work Phone #: (910- )863-3967
Date 01 21 n014
„1 certify that i 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 th 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:"
Bach -Up Operator in Responsible Charge (BU ORC)
Print Full Name: .DAMES ALTON BOSWELL
Certificate Type /
Signature:
rade / Number:
II
11iK9 X3 %j ef0A`
"1 certify that 1 agree to my designation as a Back-up )perator'in Responsible Charge for the facility noted. 1 understand and will abide by the
rules and regulations pertaining to the responsibilities of the DU ORC as •set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control E ystern Operators Certification Commission,"
7-1
Work Phone #: (910 ) 876-2588
Date: 01/21/2014
.Mail, fax or email the
• original to:
Mail or fax a copy to the
appropriate Regional Tice;
WPCSOCC, 1618Mail Service Center, Raleigh, NC 27699-1618
is i(arsidary
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax; 828.299.7043
Phone: [phone]
Washington
943 Washington £ q Mali
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Fax: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresvnie 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
585 Waugbtown St
Winston-Salem 27107
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 02-2013