NC0078955_Operator Designation Form_20160118

`From:
01/08/2016 10:58 #006 P.001/002
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north carolina
city of dunn
Fax Transmittal Form
To From
Name:__C 22 WR
Attention:__
Fax Number:_ qL Q_-414 4 - V
Info. You Request 0
Reply Requested Q
Urgent Attention Needed 0
Name: Li; 12
Phone: [phone]
Fax: [phone]
E-mail: q_..jrck AtAil i1..`
Date Sent: ,1 r l
1.2
Number of pages including cover sheet:_
Information Details/Comments
le- a‘„>.,„_
DUNN
tAraid
City of Dunn Public Works
P.O. Box 1065
Dunn, NC 28334
[phone]
[phone]

' From: 01/08/2016 10:58 #006 P.002/002
Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name: Lf /'' j (l 1, IPttvu" AMA 1GQ .D1 LC(17
I
Mailing Address:
City: 0(,t.A01. State: NC, Zip: 23 �3� - Phone #: �� - �. 3� ' , cQ
Email address:pit. it. ( (,(yl� - G, OP -
Signature: Date: /`C/217
Facility Name: OC nn Permit #: �'O � $C1s5
County:
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Gr CHECK ONLY ONE):
Biological Collection hiysical/Chemic 1 Surface Irrigation Land Application
Operator in Responsible
Charge (ORC)
Print Full Name: E✓l� l t C1(06-'S
Certificate TT pe / Grade / Number: PC r16t bi
Signature: 310.4ti> )�
Email: G11..f r 01Q.1- •n G * O 1 �i
Work Phone #.Lq, I E.)) r- 51 a-C
Date:
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: Crr J 719 / 4ta�Jt .- ,?t,7 4 Email: (j uUgC / 15.6-g-170,1-hwF /, rj' c?Yr't
Certificate Type / Grade / Number: Pc / 997 ?6,7 Work Phone #: 9//% " �f �'r% ` g/ o� 9
Signature:rZ4.11,a2d( Date: / — ^j - /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 15A NCAC 08G .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:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
Email: certadiriii Oncdenrcgov
Mail or fax a copy to the Asheville Fayetteville Mooresville Raleigh
appropriate Regional Office: 2090 US Hwy 70 225 Green St 610 E Center Ave 3800 Barrett Dr
Swannanoa 28778 Suite 714 Suite 301 Raleigh 27609
Fax: [phone] Fayetteville 28301-5043 Mooresville 28115 Fax: [phone]
Phone: [phone] Fax: [phone] Fax: [phone] Phone:[phone]
Phone: [phone] Phone: [phone]
Washington Wilmington Winston-Salem
943 Washington Sq Mall l27 Cardinal Dr 450 W. Hanes Mall Rd
Washington 27889 Wilmington 28405-2845 Winston-Salem 27105
Fax: [phone] Fax: [phone] Fax: [phone]
Phone: [phone] Phone: [phone] Phone: [phone]
Revised 05-2015

Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name: C1 t vi i,„) /Rok.14 ,I i,t t
--7
Mailing Address: e t) . 0 x IV 17 S
City: .-P(A,tL101, State: IVC, Zip: OW -
Email address: le , dk. 0 d l,(yt/A - jtc-, Oki
Signature: /% r Date: ACP-16
Facility Name: CA -At O� V= r r
County: k\Pte-6 E'(T
Phone #:
Qld -a-30-302.
Permit#: V%C5-5
.Dal
DEQ/DWR
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Gr CHECK ONLY ONE):
Biological Collection ysical/Chemic 1 Surface Irrigation Land Atj
FAY.ETIEV.11.I.E.REGIQNAL OFFICE
Operator in Responsible Charge (ORC)
Print Full Name: c)ftr(Ve..\0t_ � CitAriet>5 Email: C .. nrl t t @alk-ANS.N G • b
Certificate T e Grade / Number: P� �q 1 1' 10� Work Phone .#k51b>$S� • 51 Q-R
Signature: 0.. PatiWqk A Date: 1 .'14 b
JAN 13 2016
"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 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: ery,f7'-4 / A.e6 e c/4e-r4-A
Email: Cht,t4b rc 5.- ,17 *r r /,
Certificate Type / Grade / Number: pc / 99 7 ?(a 7 Work Phone #: 9/0 - g•-• /77 - s'7 ? 9
Signature:
Date: -/ -'7 - /& -
"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, fax or email the
on final to:
Matlq fax a copy to the
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
Email: certadmin(&ncdenr.gov
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville �� �-Q h e Mooresville
225 Green, St 610 E Center Ave
Suite 714 `' Suite 301
Fayetteville 28301=5043,j1 Mooresville 28115
Fax:[phone] Fax: [phone]
Phone: [phone] Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
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