NC0003719_Operator Designation Form_20190326

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WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORNIEQ/DWR
NCAC 15A 8G .0201 APR 02 2019
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Facility Name: DAK AMERICAS CEDAR CREEK SITE
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Permit # FAYE3 �C1Qd3I
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Facility Type: WW Facility Grade: I1 SUBMIT ASEPARATE .FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: Matthew P. Hendrickson
Email Address:
[e-mail]
Permittee, Signatu re:
Full Name: Sharon Smith Frost
Email Address-
[e-mail]
Certificate Type. WW
Signature:
Full Name:
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Certificate Grade: IV
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Work Phone:
Certificate #:
Effective Date:
[phone]
994532
"1 certify that 1 agree 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 15A NCAC 08G .0204 and
failing to do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
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Robert Lee Robinson
Certificate Type: WW
Signature:
Full Name:
Certificate Grade: III
Work Phone:
Certificate #:
[phone]
987846
Effective Date: 7 0 ? 2S
"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."
Conrad Adair Lyle
Certificate Type: WW
Signature:
Certificate Grade: II
Work Phone:
[phone]
Certificate #: 27780
Effective Date: 'i// /p3
"1 certify that 1 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."
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

Page 2
Facility Name: DAK AMERICAS CEDAR CREEK SITE Permit #:
Full Name: Elizabeth M. Wike
Certificate Type: WW
Signature:
Full Name:
Sac
Certificate Grade: IV
NC000371 9
Work Phone:
Certificate #:
[phone]
996801
Effective Date: 2 6/„2_dl7
"1 certif}that I agree to my designation as a Back-up 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."
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Certificate Type: Select
Signature:
Full Name:
Certificate Grade: Select
Work Phone:
Certificate it:
Effective Date:
"1 certify that 1 agree to my designation as a Back-up Operator in Responsible Chargefor 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."
Certificate Type: Select
Signature:
Full Name:
Certificate Grade: Select
Work Phone:
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 15A NCAC 08G .0204 and failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Certificate Type: Select
Signature:
Certificate Grade: Select
Work Phone:
Certificate #:
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."