NC0078955_Operator Designation Form_20131018

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC
15A 8G .0201
Permittee Owner/Officer Name: C 1+ 0'b pot /i&t 1(� p, / b i 4
Mailing Address: poi goK (U4,
`
City:
EN —F C
OCT 3 1 2013
V L-h 1A State: AUG Zip: -$13.5": Phone #: ( `f 10) gin,- '' I) L
Email address: at &t tt — y1, C , b r9
Signature:
Facility Name: , 6, Iit.7-z 'e, T p
Date: /a
Permit #: pc t O' $ 95
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility %pe/Grade:
Biological WWTP
Physical/Chemical_
Collection System
Surface Irrigation
Land Application
Operator in Responsible Charge (ORC)
Print Full Name: allrify I Tk a t e
Certificate Type / ade Number: 'N b t -3 3 Work Phone #: () 9 ? — f f/a4
Signature: LI
Date: .GQ'�
"I 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 socanresult in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
••44
I � I
Print »eJ Full -Name: pa-Q. T ( YV1,L/11 (S 1 1
Certificate T / Grade / Number: PC ( f q 7 q b' Work Phone #: ((flO) ��% •/ — 51?cl
Signature: - "atU 4— ,EL4 Date: /) " 30 /3
"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 the original to:
Mail or fax a copy to the.
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043..
Fax:: [phone]
-Wilniiington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Winston-Salem
585 Waughtown St
Winston-Salem 27107
Fax: [phone]
Raleigh
3800 Barrett Dr`
Raleigh 27609
Fax: [phone]
Revised 6-2012

1 J a
Facility Name:
a, a. u-1,11e wTP
Back -Up Operator in Responsible. (/Charge (BU ORC)�
Print Full Name: a VI,Gt. 1M JO( Fats G(
Permit #: NC 6 d 1 43T yc
Certificate Type / Grade / Number: Pc 6 7 7 _ Work Phone #: (`O) ' "('1- 5/rf 1
Signature:
/6[ Date: ifye. /- //
"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."
Back -Up .Operator in Responsible Charge (BU ORC)
PrintFull Name:
ame: �1 q / n
Certificate Type / Grade / umber: ! CI '1q 9 [ b I Work Phone #: ( ?ID ) q % — 0.2- 1
Signature: e,. o� �u �- Date: 1G/3 o f /3
"I certify that agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understandandwill 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
�(B`U� ORC)
Print Full Name: P€0._ [)'j J 6 6-
Certificate T e / Grade / Number: ,'C_ 6 979 (vie Work Phone #: (9) b ) gQ '"7 • Si a 9
Signature: }� ` 1 Date: /04-1/4-5
"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."
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
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 6-2012