NC0035904_ORC Designation Form_20140722

Water pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
PermitteeOwner/Officer Name: Wj11iam N. Stovall, PE, Director of Engineering
Mailing Address: NC DPS, Central Engineering, 4216 Mail Service Center
City:. Raleigh
State: NC Zip: 2 7 6 99 .. 4 216 Phone #: (919 ) 716 - 3 4 0 0
Email address: bill • stovall©ncdps . gov
Signature:
Date:
Facility Name: McCain Correctional Hospital Permit#: WQC500263
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade:
Biological WWTP ' I I Surface Irrigation X
Physical/Chemical Land Application X
Collection System I I
Operator in Responsible Charge (ORC)
Print Full Name: Philip W. Smith
Certificate Type / =de/Numb-jCS II 1000020 Work phone#: [phone]
Signature:
Date; & - 30 -
"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 Coraunissiou."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name: Thomas L. Criscoe
Certificate Type / . de I Number: CS 119 9 4 013
Signature: ,
Work Phone #: 0 :12 81- 3161
Date: 7-).-/L
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted.l understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as sot 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"
Mall, fax or email the WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax; 919.71.5.2726
original to: Email: certadmin(ainedenr.t ov
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; 919.571.4718
Phone: [phone] Fax:910A86.0707 Fax:[phone] Phone:[phone]
Phone:[phone] P1.sone:704.663.1699
Washington Wilmington Winston-Salem
943 Washington Sq Mall 127 Cardinal Dr 585 Waughtown St
Washington 27889 Wilmington 28405-2845 Winston-Salem 27107
Fax: [phone] Fax: [phone] Fax: [phone]
Phone: [phone] Phone: [phone] Phone: [phone]
Revised 03-2014