NC0003719_Operator Designation Form_20150708

Jul 0815 10:45a Dak Americas Allbright
-_c
9104338387 p.1
DAK Americas
FIBERS„MONOMERS & RESINS
3216 Cedar Creek Road
Fayetteville, NC 28312
Phone: [phone]
Fax: [phone]
FAX
To: FRO
From: Donald Allbright Date: 7/8/2015
Title: Waste treatment ORCI Safety/Health/
Environmental Technician
BACK UP ORC DESIGNATION FORM
PAGES: 2 INCLUDING. COVER SHEET

Jul 081510:45a Dak Americas Allbright
- 9104338387 p.2
Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A SG .0201
Permittee Owner/Officer Name: DCliv ALL At t.132 16 t- T
Mailing Address: 32.1 c, CE C A CizFE � RO
City: I [ F TTEY1 LU State: C. zip:078310 - Phone #: QlO - 4/33 - 6' aa�
Email address: 1)Aal lb r10h1 dG 0, re- c IC0,S 0. COn-\
SignatureZCW\c294.
Date: ks
Facility Name: b 11YL E 21C
County: CLfri b€ - I4 Y\iCJ
Permit #: JZICC)003? t 9
Biological
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
Collection Physical/Chemical Surface Irrigation Land Application.
Operator in Responsible Charge (ORC)
Print Full Name: Email:
Certificate Type / Grade / Number: Work Phone #:
Signature: Date:
"1 certify that I 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."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Rob e -I Le Az; i saN -JR Email: Rl c e m aaPi s c a'Arc • 1?R• corn
Certificate Type / Grade / Number: WWII/ `T S7 g y6 Work Phone #: 91 o At 3 3: 3 2 32
Signature: f t
Date:
"I 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 BU ORC as set forth in 15A NCAC 089 .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email the
original to:
Mail or fax a copy to the
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center,
Email: certadmin(aitncdenr.eov
Asheville
2090 US Hvey 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Raleigh, NC 27699-1618
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
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 05-2015