NC0035904_ORC Designation Form_20200127

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Permittee Owner/Officer Name:
Email Address:
Permittee Signature:
Facility Name: McCain Correctional Hospital
Press TM to enter information
NC Department of Public Safety/Scott Smart, PE
Randolph.Smart@>ncdps.gov
Date:
Permit # NC0035904
SUBMIT A SEPARATE FORM FOR EACH CLASSIFICATION OF SYSTEM: Facility Type: WW
Facility Grade: II
Print Full Name: Phillip Smith
Certificate Type: WW
Email Address: Ph'
ORC - OPERATOR IN RESPONSIBLE CHARGE
Work Phone:
Certificate #: -.9 0,944-2939 !o b 3
Certificate Grade: it
s.gav
910-944-2939
Signature:, ? "'' Effective Date: - "ScP
"! certify that l agree to my design tlon as the Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining `t the responsibilities of the ORC as set forth in 25A NCAC 03G .0204 and foiling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certifcotion Commission."
BACKUP ORC
Print Full Name: Ricky Kevin Lee
Certificate Type: WW
Email Address: Ricky.Lee©ncdps.gav
Certificate Grade. I�
Work Phone: [phone]
Certificate#:
Signature: pi!'`...._-C..- _.T..
Effective Date:
993587
1 certify that 1 agree to my designation os o 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 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."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
ORIGINAL to: Email: r.o; tacirninei nc etr. ;ov Fax: [phone]
Mail or Fax a COPY to: Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800
sleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 82019