NC0028916_Operator Designation Form_20130326

03-26-' 13 12:15 FROM -Town of Troy
[phone] T-722 P0001/'I CL12 F-049
Water Pollution Control System Operator Designation Form.
wPcsocc
NCAC 15A. 8G .0201
Permitter Owner/Of cer Name: le,x44 a'F %41
Mailing Address: ew►u e�
City: rJ / _ Stag:: JZip 4{ Phone #: ( ) c f
Signature: may- /l c d Date: 3— i "/3
Facility Name: . U e.1\) c)"F % by p T kit Permit #: o-a m--(
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM !
Facility Type SE Grade:
Type
l3iologieal WWTP t�
Physical/Chemical
Collection System
Grade
.Surface Irrigation
Land Application
Type Grade
N/A_
N/A
Operator in Responsible Charge (ORC)
Print Full Name:
_1' _ : t E r,i) S
Certificate Type / Gradel/ Number: Z(J(.v 9 53 Work Phone #: (/ ) r. CD/ .
Signature:
Date: ~ -9- -t
"I certify that I agree to. xi designation as the Operator in Responsible Charge for the facility noted. 'understand and will abide by the
riles and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 080 .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Corninission."
Back -Up Operator in Responsible. Charge (BU ORC)
Pririt Ful] Nartre:
D 'i4iS y
Certificate Type / Grade / Number: �=
Signature:
S 5
F ex ' ���
Work Phone #: (Y/C) ) ,7"?0JJs./-3c291 Dat:." Co -/-..
"I certify that I agree to rtty designation as a 13acic-up Operator in Responsible Charge for the facility noted. I understand arid will abide by
the rules and regulations pertaining to the responsibilities of the BTJ OKC as set forth in 15A NCAC 080 .0205 and failing to do so can
result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail or Fax to:
WPCSOCC
1618 Mail Service. Center.
Raleigh, NC 27699-1618
Fax: [phone]
Fayetteville Regional Office
225 Green St. Suite 714
Fayetteville, NC 28301-5043
Fax:[phone]
(See next page for designation of additional back-up operators. De:;ignation of more tban one back-up operator. is Optional.)
Revised tt-2007