NC0028916_Operator Designation Form_20170508

RECEIVED
DEQ/DWR
W ter Pollution Control System Designation Form MAY 1 0 2017
wPcsocC
NCAC 15A:08G .0201
General Information:
Permittee Owner/Officer Name: r
Mailing Address: 3) 5 /J /1'7/1(;-1
WQROS
FAYETTEVILLE REGIONAL OFFICE
City: i 12.0 State: Zip: 2i 7 3,/
Telephone Number (q(/d ) S-7 7-- 3661 Fax Number (9 (°) 5 ? -- 3 GAO 3
Signature: Date: 5-- - / 7
Facility Information:
Facility Name: r' L.i /2c
Permit Number: Ale CO 'an ( C County: /7/0��f?�C`-
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM !
Mark (X) Type of Facility
Wastewater Plant
PhysicaUChemical
Collection System
ty
Grade
Mark (X) Type of Facility
Spray Irrigation
Land Application
Operator in Responsible Charge:
Print Name: gy/f J
Certificate Type and Grade: CU t) Li Certificate #: 52(77
Work Telephone: (7l I ) 71 »- (OD `SS- Signature:
Back -Up Operator in Responsible Charge:
Print Name:
Certificate Type and Grade: (f G�J T
Work Telephone: (q/o ) 2 <2 -015-7 Signature:
Mail or Fax to:
Certificate #:
WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618 Fax: [phone]

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Permit Number. )J G. Page 2
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Back -Up Operator in Responsible Charge:
Print Name: firc, S - OA De r
Certificate Type and Grade: Li
Certificate #: qcti 1f3
Work Telephone: (q fd) - O7S3 Signaturey,717
Back -Up Operator in Responsible Charge:
Print Name:
Certificate Type and Grade: Certificate #:
Work Telephone: (_� Signature:
Back -Up Operator in Responsible Charge:
Print Name:
Certificate Type and Grade: Certificate #:
Work Telephone: ( )
Signature:
Back -Up Operator in Responsible Charge:
Print Name:
Certificate Type and Grade: Certificate #:
Work Telephone: ( )
Signature:
Back -Up Operator in Responsible Charge:
Print Name:
Certificate Type and Grade: Certificate #:
Work Telephone: ( ) Signature: