NC0023957_Operator Designation Form_20160222

02-25-16 08:14 FROM -Cross Creek
9104841228
T-101 'PO00110004 F-393
Cross Creek Water Reclamation Facility
Fax to number:
Attention:
Date;
From:.
Number of pages:
(Including Cover Sheet)
Additional GOrntrerifg:
Cross Creak Water Reclamation
Facility
Public Works Commission
P.O. Box 1089
FayetteviEle, NC 28802
Phone [phone]
FAX .(91.0) ••.: • •
I V‘).- ci%— 0962
17-i7ek-
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• Building Community Connecgons fot: a Cencuiy
-1905-100tIrAnniversary-L•2005 ' •
•

E12-25-'16 03:14•FPOM-Cross Creek 9104841228 T-101 PO002/0004 F-393
Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name; M.J. Noland, Chief Operations Officer WR
Mailing Address: FO Box 1089
City: Fayetteville
Email address:
Signature;
State: NC Zip: 28302
[e-mail]
1089 phone #: [phone]
Facility Na MC:
Cross Creek Water Reclamation Facility
County: Cumberland
Permit #; NC0023957
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
FacilityType/Grade (CHECK ONLY ONE):
Biological Collection Physical/Chemical Surface Irrigation Land Application
Operator in Responsible Charge (ORC)
Print Full Name: Michael Scott McCoy Email: [e-mail]
Certificate Type / Oracle / Number:
Signature: / /�
WW-4 #24382 Work Phone #: [phone]
G/
Date: ? T)?' 1(a
"I Certify that I agree to my designation as the Operatorin Responsible Charge for the facility noted. 1 Understand and will abide by the rules
and regulations pertaining to the responsibilities of the ORC as sot forth in 15A NCAC 080 .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: Wendell C. Baxley
Email: [e-mail]
Certificate Type / Grade / Number: WW-4 #13481 Work Phone #: [phone]
Signature:
"I certify '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'SU ORC as set forth in 15A NCAC 080 .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
A?iril,,fax or email the
' oritthuri tn:
-Maiiorfax a ej2Exto.the
appropriate' Regional Office:
WWV1'C$OCC, •1618 Maii Service Center, Raleigh, NC 27699-1618 Fax: 919.715,2726
Entail: cectainiin(atiicdi;nr:aov
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: 252,946.9215
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]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone:[phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax; 336,776.9797
Phone: 336.776,9800
Raleigh
3800 Banctt Dr
Raleigh 27609
Fax: [phone]
Phone:919.791,4200
Revised 05-2015

02-25-' 16 02: ].5 FROM -Cross Creek 9104841228 T-101 P t003/0004 F-393
WPCSOCC Operator Designation Fern, cont.
Facility Name: Cross Creek WRF
permit #: NC0023957
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Christopher M. Brigman
Certificate Type / Grade / N Zhe1•: WW-4 # 987678
/7.0 11,4 Date:
ram -
Email: chris.brigmanetypwa.com
Work Phone #: [phone]
•
•
"I ccttify that I agree to my designation as a Back-up Operator in Responsible Charge for the faoility noted. I understand and will abide by the
roles and regulations pertaining to the responsibilities of the BIJ ORC as set forth in ISA NCAC 08G .0205 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: Taylor A. Hill Email: [e-mail]
Certificate Type / Grade / Number:. WW-4 #1001102 Work Phone #: [phone]
Signature: 'Date. j# /‘
"I certify that I agrc o my designation es 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 BU ORC as sct forth in 15A NCAC 080 .0205 Enid failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (DU ORC)
Print Full Name: Anthony Gerard Jones
Email:
[e-mail]
Certificate Type%radel Number: WW-4 #25833 Work Phone #: [phone]
Date: 6f/6
Signature:
"I certify that I agr to my designate n as a Back-up peratbr in Responsible Charge for the facility noted. I understand and will abide by the
roles and regulations pertaining to t e responsibilities f the Bt./ ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water nllution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Ernest Michael Marshall Jr. Email: mike: [e-mail]
Certificate Typrr / Graclu'/ Number: ,WW-4 #14440
Signature:
Work Phone #: [phone]
Date:
"1 certify that I agree to my designation as a Back-up Operator in Reponsible Charge for the facility noted. I understand and will abide by the
roles and regulations pertaining to the responsibilities of flu BU ORC as sot forth in 1SA NCAC 08Q .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 05-2015

02-25-'16'08:15 FROM -Cross Creek 9104841228 T-101 P0004i0004 F-393
WPCSOCC Operator Desigrratiarr Form, oorst.
Facility Name: Cross Creek WRF
Permit #: NC0023957
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Halter Lee Spence Email: [e-mail]
faypwc.com
Certificate Type / t-rade / Number: WW-4 #25207.
Signature:
Work Phone #: [phone]
Date: 2.•J6-7©/‘
I certify that I agree to my designation as a Baek-up Operator in Responsible -Charge for the facility noted. I understand and will abide by the
Hiles and regulations Pertaining to the responsibilities of the 13(Y ORC as set forth in 15A NCAC 080.0205 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: James Keith Young
Entail:
keith,[e-mail]
Certificate Type / Grade / Number: WW-4 #1001107 Work Phone #: [phone]
e77.'
Signature: / � r+ Date: a -17 -"/6'
"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 BU ORC as set forth in I5A NCAC 0$G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certifioation Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: _ Email:
Certificate Type / Grade / Number: Work Phone #: _
Signature: _ . 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 BU ORC as set forth,in ISA NCAC 080.0205 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 (0(1 ORC)
Print Full Name: Email:
Certificate Type / Grade / Number: Work Phone #:
Signature: 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 BU ORC as Set forth in 15A NCAC 010.0205 and failing to do so can result in
Disciplinary Actions by the Winter Pollution Control System Operators Certification Commission."
Revised o i-2015