NC0028916_Operator Designation Form_20091209

Water Pollutio Control System Designation Form
WPCSOCC
NCAC I5A:OSG .0201
General Information:
Perm ittee Owner/Officer Name: 0 c j l2 U f
Mailing Address:
)1 tAri sue:
City: 1- a O`/ State: i•J C`�? Zip:' 2-7 71 -
Telephone Number ( q/D ) 57 .Z - %g'// Fax Number (9/O) S 72- S C`i 3
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Signature: Date: l - G / `
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Facility Information:
Facility Name: / cif cgs a \% w �3
Permit Number: NC, 00 Z-gct'l (, County: 1141:4-x}l-c) c' 1ivt
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM !
Mark (X) Type of Facility, Grade Mark (X) Type of Facility
Wastewater Plant X ! t
PhysicaVChemical
Collection System
Spray Irrigation
Land Application
Operator in Responsible Charge:
Print Name: —I > c p N E Lo
Certificate Type and Grade: GCJtL -
Certificate #: l 2_
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Work Telephone: (I/oi ) 220 7( 57 Signature:
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Back -Up Operator in Responsible Charge:
Print Name: : S i4/4 HA E i 5
Certificate Type and Grade: V'/ PC. S
Work Telephone: (/ 1(2) ? ZC -d / S Signature:
Mail or Fax to:
WPCSOCC
1618 Mail Service Center
Raleigh, I.C. 27699-1618 Fax: [phone]
Certificate #: (? ry

Permit Number:. -C. ©O Z. cei
Page 2
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Back -Up Operator in Responsible Charge:
Print Name: -711: r?^vi't s i-grzc /l 114 6iv'es
Certificate Type and Grade: iv tti Z.f Certificate #: % y 3 19
Work Telephone: (I/U) 22" "S'? Signature- /2120-)-(/_ AZ ' -/
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: