NC0004626_ORC Designation_20210609

JUN 1$ Xel
15 Nippon Electric Glass Winston-Salem
P P Regional Office
Electric Glass Fiber America, LLC
473 New Jersey Church Road Lexington, NC 27292 [phone]
June 9, 2021
WPCSOCC
1618 Mail Service Center
Raleigh, NC 27t09-1 b i $
Attached is an updated Water Pollution Control System Operator Designation Form for the NEG
Electric Glass Fiber America, LLC facility in Lexington, NC, Permit No. NC0004626. The
attached term documents the assignments of ORC and Back -Up ORC roles. Specifically, adding
Kimerly Burkhart as ORC and Todd Robinson and Back -Up ORC and retaining Richard Young
as Back-up ORC.
Designations for Electric Glass Fiber America, LLC — Lexington Plant
Name
ORC
Back -Up
ORC
Grade /
Certificate #
Requested Date
Kimerly Burkhart
X
WW4 1 10705
June 8, 2021
Todd Robinson
X
WW4 / 989809
June 8, 2021
Richard Young
X
W W 3 / 992348
tful
Steinert
Environmental Manager
cc: NC Division of Water Quality, WSRO

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 1SA 86 .0201
Press TAB to enter information
Permittee Owner/Officer Name: Electric Glass Fiber America, LLC
Mailing Address: 473 New Jersey Church Road
city: Lexington
Email Address: [e-mail]
Signature:
State: NC
aak—'
Facility Name: EGFA Lexington Manufacturing Facility
County: Davidson
Phone: [phone]
Zip: 27292
Date:
Permit # NC0004626
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type: WW
Facility Grade: ,III
0
1
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: Kimerly Burkhart
Work Phone: [phone]
Certificate Type: WW 0 Certificate Grade: IV 0 Certificate #: 10705
Email Address: [e-mail]
Signature:
(Df' 11#0 Z-I
"l certify that I agree to my design° on as the 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 1SA NCAC 08G .0204 and foiling to do so con resua in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission.`
Effective Date:
BACKUP ORC
Print Full Name: Todd Robinson
Work Phone:
Certificate Type: WW [] Certificate Grade: IV 0 Certificate N:980809
Email Address:
Signature: 7� Effective Date:
"/ 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 1SA 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:
Mail or Fax
a COPY to:
WPCSOCC, 1618 Mail Service Center, Fax: [phone]
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].
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]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone: [phone]
Winston-Salm
45 W. Hanes Mali Rd.
Winston-Salem, NC 27105
Fax: [phone]
Phone:[phone]
WOO
3800 Barnett Dr.
Raleigh. NC 27609
Fax: [phone]
Phone : [phone]o

WPCSOCC Operator Designation Form (continued)
Facility Name: Electric Glass Fiber America, LLC
Page 2
Permit #: NC0004626
BACKUP ORC
Print Full Name: Richard Young
Work Phone:[phone]
Certificate Type: WW 0 Certificate Grade: 111 Q Certificate #:992348
Email Address: Ric
Signature:
[e-mail]
1G
Effective Date: 6///?ri2/
"I certify that I agree to my designation as a B. ck-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 1 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 foiling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Fult Name:
Certificate Type: Select Certificate Grade: Select
Email Address:
Signature:
Work Phone:
Certificate #:
Effective Date:
"I certify that l agree to my designation os 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 1SA NCAC 08G .0204 and foiling 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: Effective Date:
Certificate Grade: Select
Work Phone:
Certificate #:
"1 certify that I agree to my 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 154 NCAC 08G .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."