NC0081621_Other Agency Documents_20210512

NC DEVAn i Nlciv r
ENVIRO RECEIVMENTED QUALITY
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION M
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Traivs Mark Fowler
Mailing Address: 6400 Breezy Lane
City: Concrd
iAl•
I1f4&SOCC)
MOORESVILLE REGIONAL OFFICE
DIVISION OF AIR QUALITY
Phone: [phone], x111
State: NC Zip: 28025
Email Address: mfowIer@wsa c.org /
Sign
ature: \ ` 1 + �lA— Date: 5/ /co- / a Z(
Facility Name: Muddy Creek WWTP
County: Cabarrus
Permit # NC0081621
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type:
WW ---
Facility Grade:
II -.
RECEIVED/NCDEQ/DWR
MAY 1 8 2021
WOROS
MOORESVILLE REGIONAL OFFICE
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Matthew Dwayne Isenhour
Work Phone: [phone]
Certificate Type: WW Ej Certificate Grade: IV lj Certificate #: 1002601
Email Address: [e-mail]
Signature:
5 /5 AZ 1
"1 certify that / agree to my designation as the Operator in Responsible Charge for the facility noted. / 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."
Effective Date:
Print Full Name: James Christian Sims
Certificate Type: WW Certificate Grade: IV
Email Address:
Signature:
jamessims wsacc.org
Work Phone:[phone], x114
Certificate #:999309
Effective Date:
"I certify that / agree to designation as a Back-up Operator in Responsible Charge for the facility noted. / understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC O8G .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:
Mail or Fax
a COPY to:
WPCSOCC, 1618 Mail Service Center,
Raleigh, NC 27699-1618
Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fax: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Email: [e-mail]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mall Rd.
Winston-Salem, NC 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 4/2016

WPCSOCC Operator Designation Form (continued)
Facility Name: Muddy Creek WWTP
Page 2
Permit #: NC0081621
BACKUP ORC
Print Full Name: Nicholas James Merwin
Work Phone: [phone], x118
Certificate Type: WW Certificate Grade: IV aCertificate #:1006823
Email Address: [e-mail]
Signature: `^^' Effective Date: 5- 3- Z
"I certify that l 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 Operators Certification Commission."
BACKUP ORC
Print Full Name: Kimberly Dawn Holt
Certificate Type: WW
Work Phone: [phone], x118
Certificate Grade: IV El Certificate #:993802
Email Address: kimholt©wsacc.org
Signature:
Effective Date: 3-- 3-- .J
"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: Christopher Scott Yost
Work Phone:[phone], x118
Certificate Type: WW Certificate Grade: II Certificate #:1002797
Email Address: [e-mail]
Signature:
- (, I� Effective Date: £— b l 2-0
1 certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. l 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: Adam Neal Love
Certificate Type: WW
Email Address: [e-mail]
Signature:
Work Phone:[phone], x118
Ej Certificate Grade: IV LI Certificate #:1008206
1
Effective Date:
"I certify that I agree to riiy designa on 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."
Revised 4/2016

WPCSOCC Operator Designation Form (continued)
Facility Name: Muddy Creek WWTP
BACKUP ORC
Print Full Name: Braden Joshua Cook
Certificate Type: WW [ Certificate Grade: IV
Email Address:
[e-mail]
Signature:
Effective Date: 5.w-2� --
m
"I certifythat 1 agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by
5Athe rules and regulations pertaining to the responsibilities of the ORC as set forth in Certi ication Co1mmN s on08G'0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operatorsf
Permit #: NC0081621
Page 2
Print Full Name: Karen Renee Marie
Certificate Type: WW El Certificate Grade: IV
Email Address: [e-mail] �T �_�/
Effective Date:
Signature: Effective
as a Back-up Operator in Responsible Charge for the facility noted. 1 understand and will abide by
the ruleslthat r agree to s py g
and regulations pertaining to the responsibilities of the ORC as set forth in 15A Certi ication CommN CAC sionOSG .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators f
Work Phone:[phone], x118
Certificate #:1002815
Print Full Name: Hope Elizabeth Seger
Certificate Type: WW
Email Address: [e-mail]
Effective Date: Jam- �o " Z�
Signature:cility noted. I understand and
"1 certify that 1 agree to my esignation as a Back-up Operator in Responsible
orth in 15A NCACafor the 08G .0204 and failing to do so caln aes�lt in
by
fY
the rules and regulations pertaining to the responsibilities of the ORC asf
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Work Phone:[phone], x118
Li Certificate #:1002612
ID Certificate Grade: I
BACKUP ORC
Print Full Name: Kevin Morgan Graves
Certificate Type: WW Certificate Grade: IV
-
Email Address: [e-mail]
Signature:
Effective Date: 5'3 2.05.1
. .
desi gnat • n as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by
y
certify
rules and regulations
that r agree toegulationss p
thepertaining to the responsibilities of the ORC as set forth in Certification Co15A mm� CommCAC ission."
.0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Revised 4/2016
Work Phone:[phone], x118
Certificate #:1010041
Work Phone:[phone], x118
El Certificate #:999374