NC0028916_Operator Designation Form_20190717

Water Pollution Control System Operator Designation Form
WPCSOCC
+� NCAC 15A 8G .0201
Permittee Owner/Officer Name: Efln Den>>, 1
`S 9
FRC publicof a �
water supply
�uAAIy
sources
Mailing Address: 3 is- 1" I I G>ir S -
City: "-Cm / State: PC- Zip: a ?C 3-7 1- Phone #:
11
Email address: 6enn y o de 0 n.'5 @ / ma; ``; IVED
Signature: 6.04'M� I.>�P%1- 's
DEQI )VvR
Facility Name: -1-01,JeN 0 i' `(-,-.1
County: H I J or` °c;v , .�1;� s �� _' c glNA`..OFFILE
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM! /V/S! - Qom' • ?
Facili Type/Grade(CHECK ONLY ONE):
2019
ty yP )
ollection Physical/Chemical Surface Irrigation Land Application vvalsr Sups`
Date: 7-/7-1 9
Permit #: � C 0 Da $'3 / (o
V' 'SOS
Operator in Responsible Charge (ORC)
Print Full Name:Bry an l{ e. (jot-leS
Email: -f-ro (PS7 G-
Certificate Type / Grade / Numb: 1/1/ W q(5`/ 27 Work Phone #: 7b 4-1-7 9 co' (D L13
Signature:
Date: 7 AA
"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 Commission."
Back -Up Operator in Responsible Charge(BU ORC) II "��
Print Full Name: D6iin Q 5ite. 1115 Email: Clp nri s m i 1 ! 5 . 1 C:.l) (Id 1 co ry .
Certificate Typ Grade / Number: / Q gg5766 Work Phone #: 170 a -
Signature: /714t_G_
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 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."
Mai4 fax or email the
original to:
Mail or fax a copy to the
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
Email:-certadmin(incdenr gov
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 05-2015