WQCS00209_Water Pollution Control System Operator Designation_20210614

Permittee Owner/Officer Name:
Mailing Address:
City:
Email Address:
Signature:
Email Address:
Signature:
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATIOIVORM (WPCSOCC)
NCAC 15A 8G .0201 c�D�CNR/D
407
SUN2a2021
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Office
Date: 6//4/420,a/
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State:
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Facility Name: T( h f c & Co\1- LAN ci-.
County: /PC'd^a a i, J 2" S
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type:
Select
Facility Grade:
Select
OPERATOR IN RESPONSIBLE CHARGE (ORC)
Print Full Name: A\ Cyj, cut.:5'I AJ
Certificate Type: Select cat k,c_ h' I Certificate Grade: Select L Certificate #:
Email Address: i�a�s ���i ,31 � 11:.�° 0�J
Signature:
4
Work Phone: 5-034o
Effective Date: Cite -1:71- 2-0 Z- t
"1 certify that I agree-t 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:
Certificate Type: Select eal/e4245" Certificate Grade: Select
giO/ /CS /M e/eli ve7, 6,2 e.. 0/71
Effective Date: ea - 6/--,gp /
Work Phone:,'-�._�
Certificate #: 2(o / 4/6
"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
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] Email::[e-mail]
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-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