HomeMy WebLinkAboutWQ0021289_Operator Designation Form_20210528WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCS
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Pamela Hurdle - Town Manager
Email Address:
Manager@townofhertfordnc.com
Permittee Signature: Yft71JJ,d L
Facility Name: Town of Hertford
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: SI
Date:
A If
5(3sia6a l
Permit # WQ0021289
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Jeremy Haislip
Certificate Type: SI
Certificate Grade: Select
Email Address: wwtp@townofhertfor1nc.com
Signature:
Wprk'Phone:
Certificate #:
252-333-6948
1010001
Effective Date: 61
1
"1 certify that 1 ag4 to my designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regula ns 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:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select
Work Phone:
Certificate #:
Effective Date:
"1 certify that / 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
ORIGINAL to:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
;Email: certadmin@ncdenr.gov Fax: 919-715-2726
Mail or Fax a COPY to: Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax: 828-299-7043
Phone: 828-296-4500
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: 252-975-3716
Phone: 252-946-6481
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: 910-486-0707
Phone: 910-433-3300
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: 910-350-2004
Phone: 910-796-7215
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: 704-663-6040
Phone: 704-663-1699
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: 336-776-9797 Phone:
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: 919-571-4718
Phone: 919-791-4200
Revised 11/2020
Facility Name: Town of Hertford
Page 2
Permit #: WQ0021289
BACKUP ORC
Print Full Name:
Certificate Type: Select
Email Address:
Certificate Grade: Select
Work Phone:
Certificate #:
Signature: Effective Date:
"1 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."
BACKUP ORC
Print Full Name:
Certificate Type: Select
Email Address:
Certificate Grade: Select
Work Phone:
Certificate #:
Signature: _ Effective Date:
"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."
BACKUP ORC
Print Full Name:
Certificate Type: Select Certificate Grade: Select
Email Address:
Signature:
Work Phone:
Certificate #:
Effective Date:
"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."
BACKUP ORC
Print Full Name:
Certificate Type: Select
Email Address:
Certificate Grade: Select
Work Phone:
Certificate #:
Signature: Effective Date:
"1 certify that I agree to my designation as a Back-up 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 Operctors Certification Commission."
Revised 11/2020