WQCS00233_Other Agency Documents_20210413

Peritee vnei
r PoHut'
Cantro System Operator Bess na
wPCSoCC
NCAC 15A 8G .0201
Name: Carolina Water Service, Inc NC
Mailing Address: .0. Sox240908
City: Charlotte
Email addr'es
Signature:
Mate: NC Zip: 28224 -
D/NCDEO/DWR
APR 1 3 ZUZ1
WOROS
MOORESVILLE REGIONAL OFFICE
704) -7R
Tony Konsul
hOST
Date:
c ccx�csF�a sascr.s..ccecszasc ner�rsccz sY��o¢� fEtstf �ais3Yifi�¢B�€stis"r8b6f&s EBfF�CifECt�K&[EE/fi@f EC6B�YEIICSE�Ef€86i{@6F��CtIR�E1rR$g£L��E�!@{$6�i8tF€EE
Facility Name: H Acres
Permit #: tAOCS00233__
SUBMIT A SEPARATE FORM FOR EA TYPE SYSTEM!
ittvTv Grade:
'cal WWTP
;icat/Chemical
System
S-2
Operator in Responsible Charge (ORC)
Print Full Name: Matthew Pairniter
Certifies Type / Grade / Number: CS-2
Signature:
L.
4
Surface irrigation
Land Application
7
.Eww..........a.
Wort l l ottc #: 910) 376-4185
Date: y_ 7" Z !
certify that la tit my designation as the E3perator in Resporisilrlc Charge for the toe€city noted, t understand and will abie1
and rep latioris pertaining to the reslrortsibiriti aftitc (SRC as set forth in I5A NCAC 080 .0204 and failing to do so can resin
Actions by the Water Pollution Control System Operators ('Certification Con mission.:'
Back -Up Operator in Responsible Charge (BU ORC)
Print Futt Name: Larry D Hens.
Certificate Type
Signature:
"I certifY that 1
rules awl regnlatis
Disciplinary Actions by the
Mail, fax or email the
original to
Mall or fax a copy to title
appropriate Regional E
ber: it
#1005519
WPC OCC, 161-
m 1lt 4%4124 l
. , lnwilr
2090 US Huy 70
Swamiama 24778
Fax: [phone]
Phone:: 828.2.96
Phone #: ( 704) 360641
l7iscip
Date: % 7- Z
afar in Responsible Charge for the facility noted. l understand and I4 It abide by the:
BU °RC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Operators Certification Commission,"
Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
Washington
943 Washington So Mall
Washirtgi n 27t189
Fat: 252,946.92IS
1'hrtrre:. 252.946.6-181
r.ffov
Fayetteville
225 Green St
Suite 714
Fayetteville 21301-5f143
Fax: 91t.4 6.t1707
Phone: [phone]
Wilmirtgtr
127 Cardinal Dr
wilm neon 28405-2A
Fax: [phone]
Phone: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax:[phone]U40
Phone: 704.6€3.1649
Winston-Salem
585 Watightoan St
W=inston-Salem 27107
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 02-2013

Facility Name: Hemby Acres
Permit #: WQCS-00233
Sack -Up Operator in Responsible Charge (SU ORC)
Print Full Name: Tommy Capps
Certificate Type / Grade / Number: CS-1 #997755
Signature: -_ Date: 7 " 2/
"I certify that I agree to my designatio 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."
Work Phone #: [phone]
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Mark R Haver
Certificate Type / Grade / Number: CS-4 #992155
Signature:
I certify that 1 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 BU ORC as set forth in 15A NCAC 08G .0205 and tailing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Work Phone #: (704 ) 361-0645
Date: 't
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. 1 understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU 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:
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."
RECEIVED/NCDEQ/DWR
APR 1 3 2021
WQROS
MOORESVILLE REGIONAL OFFI®vised 02-2013