420007_Correspondence_20210707

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Permittee Owner/Officer Name:
Email Address:
Permittee Signature:
Facility Name:
// Press TAB to enter information
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NC Dept of Environmental Qualtto
Raleigh Re
Date: 77
Permit #
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: SELECT ONE
onal Office
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: 4,,iL1y fesJ,, f
Certificate Type: Select 4 W Certificate Grade: Select 4
Email Address:
Signature:
rc.ftoi., , sir0'� ,1. eom
Work Phone: (23-2) f 7f
Certificate #:
Effective Date: 7/7/If
"1 certify that 1 agree to rrly 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
Email Address:
Certificate Grade: Select
Work Phone:
Certificate #:
Signature: Effective Date:
"1 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 ISA 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
Email: [e-mail] Fax: [phone]
Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq. Mail
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-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 11/2020

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