NC0028916_Operator Designation Form_20031029

Water Pollution Control System Designation Form
WPCSOCC
NCAC 15A:08G .0201
General Information:
Perrnitttee Owner/Officer Name: - A24- L (-- 5
Mailing Address: 7 y / N .- f111/ 4) E
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Ch : 11-0\/
Telephone Number: ( '7/O ) S7 Z — (
Signature:
State:%R—/ Zip:27g7/ -
Facility Information:
y:
Ma. ! 0 2003
Date: ! d
Facility: ) 6 1/JJ cw
Permit Number: A/C 2 Z CsY (' County: riiefiddam,, 1
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM
tAiUIJI P
Mark (X) Tvpe of Facility Glass'(? =.4} :' Class
Wastewater Plant Spray Irrigation LA
PhysicaL'Chemical Land Application N/A
Collection System Subsurface N/A.
Operator in Responsible Charge;
Print Name: 67/7// G/J.f Social Security # : z S r-'
Certificate Type and Grade: __LLI WA/
Work Telephone: C/ e )5 7c - %l't° Signature:
Certificate #: 2 '2 -5:3
Back -Up Operator in Responsible Charge:
Print Name: 4SO Clq 2A(GS S Social Security # : 239 — t/c3 —1 F
Certificate Type and Grade: / 1,0 10
Work Telephone: 0/° ) 5-72 Signature:
_. ... .
Mail,or Fax to: WPCSOCC
1618 Mail Service Center
Raleigh, iti:C. 27699-1618
Fax: : [phone]
F-Ye.`fie0; lit qle\7;nt 0 -C-r ce.
Certificate #: /' '7 7 3 •
Revised 10/2000