NC0020443_WPCS Operator Designation Form_20210514

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Certificate Type: Select /�ptr 1 Certificate Grade: Select Certificate #: /ODCD39
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the facilitynoted. I understand and ill abide bythe
"1 certify that 1 agr�to my designation as the Operator in Responsible Charge for
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."
ORC - OPERATOR IN RESPONSIBLE CHARGE
WATER P
RECEIVED MAY 26 202E
TION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
Permittee Owner/Officer Name:
Email Address:
Permittee Signature:
Facility Name:
NCAC 15A 8G .0201
Press TAB to enter information
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SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: SELECT ONE
Print Full Name:
Email Address:
Signature:
Print Full Name:
Signature:
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Work Phone: 7.$Z_706-(PSG(
Effective Date:
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Certificate Type: Select 6(/ an: I Certificate Grade: Select 1 Certificate #: 97 zet tlT
Email Address: , y� h msv Gr p ® ¥ ies "
7 Effective Date:
"I certify that I agree to my desi• nation • ap 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."
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]
ashington
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