NC0001406_ORC Designation Form_20051025

1Vater Pollution Control System ORC Designation Form
. ' WPCSOCC
1 , NCAC 15A:08G .0201 ,
General Information:
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Penniitee Owner/Officer Name: ! _st!-'''''r ! , /1/44 . /......., t 6 .•-•.0
Mailing Address: - F C5 gr-ox... 113 Lfsk
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City: E-2.(41/Q , i state: NC— Zip: 2'S 339 -
TeleplOne Number: Cij_) ! )“ 59 /" 7 Si ii-o
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Signature: 1"—F - ' _.:L Date:
!!!! Faciliti Information:
Facilit: Te.....,..,,_
Permit Niunbet: rz L 066:'')'40 Lo County: 14 r4 i■-•-.4 t 4-4-
! SUBMIT A SEPARATE FORM FOR EACII TYPE OF:SYSTEM ! '
Mark (X) Type of Facility Class (1 — 4) Class
WasteVeater Plant X "1. Spray Irrigation N/A
Physical/Chemical Land Application NA
ColleCtion System ! Subsurface N/A
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Operator in Responsible Charge;
Print Name: e-at PF..5 vJ
Certificate Type and Grade: 6,...,4 t 1or-r—Certificate #: c7 1 61
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Work Telephone: (q ID) s. signature:
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Back -Up Operator in Responsible Charge:
Print Name:Iew F, khZt*CitoNG:i g Social Security #: 211-7— - 3 14- - 7 9 8 Z.
Certificate Type and Grade: GgiVl.:-= Di 13 kot_cat cAc. Certificate #: itU, 2 67
Work Telephone: (9 o ) 97- 5-0 22- Signature:
Mail ok Fax to: WPCSOCC
1618 Mail Service Center
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social security #
Raleigh, N.C. 27699-1618
Fax: [phone]
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