NC0028916_Operator Designation Form_20120911

Water Pollution Control System Operator Designation Form
WPCSOCC -
NCAC 15A 8G .0201
Permittee Owner/Officer Name: 10CE-M l 72Lx1 1 41106 Zr ohia.• 7—-
Mailing Address: 315 f or# ` #Ftn) 5.A-re.-A-
City: I Q-c�y
Email address: 1
er
State: 14C— Zip: o2731.I ( - Phone #: (9/O ) 5'2-- 361, I
Tr NC•OS
Signature: C Date: )Il//L
Facility Name: TowN o-Q Tr€ , , (be.,
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade:
Biological WWTP Surface Irrigation
Physical/Chemical Land Application
Collection System
Permit #: Isv Q op 3'ID I D
Operator in Responsible Charge (ORC)
Print Full Name:J ct SO n ►"1 e. * heu Q r- c
Certificate Type / Grade / Number:Ia6.3/955/ 3
Signature:
Work Phone#: OS/2 )o2�6) O?a3
Date: ^ /O ! 02
"I certify thatvl 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)
Print Full Name: T oivt}-M cL
Free mom, 3-
Certificate Type / Grade / Number: l.Ut , l `q4G oq 0 Work Phone #: (9) O ) 5'7Z - 3(. (, l
Signature: % Date: RI
1 l 1 z
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I un erstand 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."
Mail or fax the original to:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
Mail or fax a copy to the Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
appropriate Regional Office:
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Winston-Salem
585 Waughtown St
Winston-Salem 27107
Fax: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Revised 6-2012