NC0028916_Operator Designation Form_20030819

ater Pollution Control System Designation.. Form,
WPCSOCC
NCAC 15A:08G .0201
General Inforznatiori:
Permittee Owner/Officer'Narne: - - CTF-,PH %4:L .5
Mailing Address: ''T '1- X/ . 41
City: 7.o`1 State: /4 C. Zip: a`T3'l 1 -
Telephone Number: (7/ 0 ) 5 — 3 Cpep /
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Signature: �� -- /mil C�� Date: 0 8 q / t -
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Facility Information:
Facility: (o ii) (� F 1 O7 " •
Permit Number: `/i]\T C 0 s+���j( /6 Coimty: i _ - : ' ' 1 • 4` •
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SUJU IT A SEPARATE FORM FOR EACH TYPE OF SYSTEM
Mark OQ Type of Facility Class (1-4) - Class
Wastewater Plant
Physical/Chemical
Collection System
Spray Irrigation
Land Application
Subsurface
N/A
N/A
N/A
Operator in Responsible Charge:
`UF -
Print Name: ; t �1 (- ,:�-1 I,��k" Social Security # : 2' r l� - nf4-- 1 0
Certificate Type and Grade: 1.1A:v/ Certificate #: !L
Work Telephone: (y / O) Li 7. l 12 F Signature: %? • 7-
Back-Up Operator in Responsible Charge:
Print Name: j
Certificate Type and Grade: .L Win:
Social Security # : 9_-4t3 1
Certificate #: J •s r/ 7 .4
t (;0,4,Admalt..4.Work Telephone: (i(C)) �! -;;�5 �t ( signature`
Mail or Fax to:
WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]
j— ‹,` ev; lit riej io itci I 0�`�� ce
Revised 10/2000
V413 ;2 2' 20r
9!l-� 900/ZOO'd 014-1 -AM NOZ:ZO sou-so-mi