NC0021253_Delegated Authority_20210506

PUBLIC SERVICES DEPARTM
104 OUTER BANKS DRIVE
PO BOX 368
HAVELOCK, NC 28532
252-444-6409
www.HavelockNC.US
Fax [phone]
May 6, 2021
Mr. Robert Tankard
943 Washington Square Mall
Washington, NC 27889
Mr. Tankard,
Please be advised of the following changes at the City of Havelock's Waste Water Treatment
Facility, permit number NC0021253. Mr. Jeffrey Jarman, certificate number 13491, will serve as the
Plant Operator in Responsible Charge. Mr. Tracy Miller, certificate number 105193, will service as
the Plant Back-up Operator in Responsible Charge.
Please let us know if you have any questions.
Public Services Director

Press TAB to enter information
Permittee Owner/Officer Name: M.) / 1 C( . L e vvl s , - 1'
i,u f ewl'S have IOck-nc . u5
Email Address:
Permittee Signature:
Facility Name:
o.). OP 1-&A.I/Ct06/c-
94
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSO
NCAC 15A 8G .0201 #41,
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9e94o,:s,
Qi,/
Date:
Permit # /1/6
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: SELECT ONE
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: 'F Vh o ^1 Work Phone:
Certificate Type: Select 6)435,...1r 0,,,_ Certificate Grade: Select Certificate #:
Email Address: PP') co 0-2 ) jk3 0
f31/9/
Signature: Effective Date:.s:NZ.,%
"1 certify that / agree to my designation as the 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."
BACKUP ORC
Print Full Name:
Certificate Type: Select
Email Address:
Signature:
"1 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 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."
Certificate Grade: Select
Work Phone:
Certificate #:
Effective Date:
Mail, fax or email
ORIGINAL to:
Mail or Fax a COPY to:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Email: [e-mail] Fax: [phone]
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
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 11/2020

Facility Name:
Permit #:
Page 2
BACKUP ORC
Print Full Name:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select
Work Phone:
Certificate #:
Effective Date:
"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 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."
BACKUP ORC
Print Full Name:
Certificate Type: Select
, Email Address:
Signature:
Certificate Grade: Select
Work Phone:
Certificate #:
Effective Date:
"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 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."
BACKUP ORC
Print Full Name:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select
Work Phone:
Certificate #:
Effective Date:
"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 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."
BACKUP ORC
Print Full Name:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select
Work Phone:
Certificate #:
Effective Date:
"1 certify that 1 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 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."
Revised 11/2020

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WP@CC) 644
0
NCAC 15A 8G .0201
Press TAB to enter information
Permittee Owner/Officer Name:
Email Address:
Permittee Signature:
Facility Name: ' 4" J
14)l' I I' i e (irkL- - L W) 5 r
w le fru 16 hay?,1 o c k-vz-c • u S
II e. Ve 10 G
Date: 575/
Permit# NC0U11 01,53
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: SELECT ONE
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: rTE Wiegi p ytr o a
Certificate Type: Select (a435,,./10Certificate Grade: Select
Email Address: j,'i) •Jz,j„ / J c � ,mow,' f . C. 0,11
Signature:
Work Phone:
Certificate #:
7/f-33or-bv67
fSY9,
Effective Date: _Si/Z_/
"1 certify that i agree to my designation as the 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."
BACKUP ORC
Print Full Name: Tracy Miller
Certificate Type: Select Biological Operatcgertificate Grade: Select
Email Address: [e-mail]
Signature:
3
Work Phone: [phone]
Certificate #: 1005193
Errap Oilier
Effective Date: 5/3/2021
'7 certify that l agree to my desiration 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 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
ORIGINAL to:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Email:[e-mail] 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
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Reviead 11nn9n