NC0043176_Operator Designation Form_20080812

Water Pollution Control System ORC Designation Form
NCAC 15A:08G .0201 ; r �t,
General. Information:
Permittee Owner/Officer Name:
Mailing = Address:
Wastewater Plant X ` , Spray Irrigation N/A-;
Physical/Chemical: Land Application N/A
Collection System Subsurface N/A
DENR-FA}�I IrJiLLEREGICINALOFFIrE� ,.
Operator m Responsible Charge:,
Print Name: ,De n r; 2 t u. k S
Back -Up Operator in Responsible Charge::. 'r'/ q
Print Name: -P60.4%. etk ifek- ; _ .. Social Security # : -44 "—Ott- 61 o l
Certificate Type and Grade:. �%Qs�e.1,,r '?�Ir `T Certificate:.#: 3
Social Security # : a37 -33 -9.5y9
Signature:
Work. Telephone: ( 7/0 ) Q.a�'44'Signature:
Mail or Fax to:
WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]

fax #:
from:
date:
re:
pages.
iNIU I b.::
CITY OF DUNN
P.O. Box 1065
Dunn, NC 28.335
tek (910) 892-299
fax [phone],
a
91(1-13- 133?
ko.
inc!uding (his cOver sheer
SP. 1 407
DENR - FAYETTEVILLE REGIONAL OFFICE

Transmission Report
Date/Time
Local ID 1
Local ID 2
2007-08-14
9108928871
Total Pages Scanned : 3
08:06:36 a.m.
re:
Transmit Header Text
Local Name 1
Local Name 2
This docum nt.: Confirmed
(reduced sampl nd detai elow)
Document size : 8.5"x11"
Crrir or. Me
P.O. Boa 1065.
Dunn. NC 23335
td (910) 092--2940
fa [phone]:
WPC sec. C— .
` 1'1 '13 - 133 ?
Litres GaSk-�
53 14-a.007
I,
/
pages. [3 including this cover iheer
11.-6 . Cie'
Total Pages Confirmed/: 3
Public Works
SAP 21 2007
. nENti-FATr ILI.Eri;
No.
Job
Remote Station
Start Time
Duration
Pages
Line .
Mode
Job Type
001
832
9197331338
Abbreviations:
HS: Host send
HR: Host receive
WS: Waiting send
Results
08:05:06 a.m. 2007-081i 4 00:00:47 3/3 1 EC HS CP28800
i
PL: Polled local MP: Mailbox print . TU: Terminated by user
PR: Polled remote CP: Completed TS: Terminated by system G3: Group 3
MS: Mailbox save FA: Fail RP: Report EC: Error Correct

9108928871
10:06:23 a.m. 05-09-2008 1/3
101 E. Cleveland Street
P.O. Sox 1086
Dunn, NC 28335
Phone:[phone]
Fax: [phone]
yorm.dunn•nc.org
Fax
To:
6trk ;14‘711e,
Fax: ?/O III D
Phone:
Re: 0
1
u 1 %i i1 114,
CITY OF DUNN
PUBLIC WORKS
From: M- uP Vk
3
Date: 5=1--O F
Pages:
cc:
0 Uryont Cl For Review 0 Please Comment 0 Please Reply
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9108928871
10: 06: 34 a.m. 05-09-2008: 2 l3
Water Pollution Control System Operator Designation Form
wPcsocc.
NCAC 15A 8G .0201
Permittee Owner%Officer Name: f 'y cr DlithY\ /go r a ie( .V i icd-
Mailing7
V
Address: fOax CG bs
City: Li h State: f k Zip: , _n5.5- Phone #: (9/0) 2�._)(;T D
Signature: 1�� Date: 5 —// ' ~Qcf---
Facility Name: C j I y D� Pit.)t IN �f /G(.Gk i/e - . Permit #: /J G d 4 4 31'7 b
f
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM !
Facility Type & Grade:
Biological WWTP
Physical/Chemical
Collection System
Grade
L
Grade
Surface Irrigation N/A
Land Application N/A
Operator in Responsible Charge (ORC)
Print Full Name: TO i1 -j e, (d H 1
Certificate Type / Grade / Number: i31D 141Pc,i0-11--7904(13 Work Phone #: (%/O) 4g71)--" 043S
Signature: e'Yvt-c .i Date: ..51q f p -
` 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 Respo nsible Charge (BU ORC) Print Full Name: ;L1hI,h G 1�l/�,{�D� / Q l 11 e-v.
Certificate / Grade / Number: !oWC50 ` 77I l3 J Work Phone #: (f /d) 11P--T ,/5.
Sn Date: 5/ �%/Oe
Signature: � �,dC��../
"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 08G .0205 and failing to do so can
result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail or Fax to:
WPcsocc
1618 Mail Service Center
Raleigh, NC 27699.1618
Fax:[phone]
(See neat page for designation of additional back-up operators,Designation of more than one back-up operator is optional.)
Revised 1-2008

4
9108928871
10:07:01 a.m. 05-09-2008 3/3
Additional Back-up ORC designations
Facility Name: Git/ D Da h 11 Nack ft Waff Permit #: AIC- bb 31 q 1
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
LI( 5%0A Giffele-
Certificate Type / Grade / Number: Vito 0K3-O-11' [ b�'8�b3 Work Phone #: (PO )'gY - p 9-T
Signature: i�t�� CCT--' �5 Date: J " r d 4
"'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 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)
lPrint Full Name: I3 [ / 1 / Wetf0 h 0113o h,
�) /n� f Q/Il�q �p
Certificate Type / Grade / Number: 00 W PC5(i -/ 6 D'f" p Work Phone #: (9'/O ) 0 V-q/-
Signature: 14 /L-L�iDate: .-^ y C) v F(
"I certify that I agree td 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 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:
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 riles and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A 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:
Certificate Type / Grade / Number: Work Phone #: ( ).
Signature: 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 BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can
result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 1-2008