WQCS00197_Operator Designation Form_20210601

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM 6WPCSOCC)
NC epartmentc
NCAC 15A 8G .0201 Environmental Quality
Received
Press TAB to enter information
JUN 0 1 2021
Permittee Owner/Officer Name: Kamara Barnett, Town Manager
Email Address: [e-mail]
Regional Office
Permittee Signature: I 6f 4A_ n0xj- Date: b. 0LI 'oca/
Facility Name: Town of Yanceyville Collections Permit # WQCS00197
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: SELECT ONE
ORC -'OPERATOR WRESPONSIBLE,.CHARG
Print Full Name: Mark Guthrie Work Phone: [phone]
Certificate Type: CS El Certificate Grade: I El Certificate #: 15322
Email Address: mainte once@ anceyville gov y
Signature: Effective Date: �7 2a:/ 1 Z
"1 certify that 1 agree to my designation as the Operator in Responsible Charge for the facility noted. 1 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."
BACKUP ORC
Print Full Name: Justin Lee Chandler Work Phone: [phone]
Certificate Type: CS El Certificate Grade: I Q Certificate #: 100774
Email Address: [e-mail]
Signature:
Effective Date: S / r) I / .30 A I
"I certify that I agree to My designation as a Back-up 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."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Raleigh, INC 27699-1618
ORIGINAL to: 'Email:[e-mail]; Fax:[phone]
Mail or Fax a COPY to: Asheville Fayetteville Mooresville
2090 US Hwy 70 225 Green St., Suite 714 610 E. Center Ave., Suite 301
Swannanoa, NC 28778 Fayetteville, NC 28301-5043 Mooresville, NC 28115
Fax:[phone] Fax:[phone] Fax:[phone]
Phone:[phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax:[phone]
Phone:[phone]
Phone:[phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax:[phone]
Phone:[phone]
Phone:[phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax:[phone] Phone:
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax:[phone]
Phone:[phone]
Revised 1112020