NC0020842_Operator Designation Form_20210708

Water Pollution Control System Operator Designation Forq--
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name: De',Nis
Mailing Address: P° ap zco
City: _Ct/064 I71
Email address:
Signature:
State: Aft Zip: Z rs10 -
Ivian/agrr e se/0 4,/(Nc. roit,►
Phone#: ZSZ Y7 -3
UL 132011
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Date: S 1-a, 2 de -
Facility Name: c/10 Lt/
County: 6 re &// e
l/ Wwrp
Permit #:
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
Collection Physical/Chemical Surface Irrigation Land Application
Operator in Responsible Charge (ORC)
1/01
Print Full Name: Email:
Number: Work Phone #:
Signature: Date:
"I certify that I agree to my desi bie s t e Operator in Responsible Charge for the facility note rstand and will abide by the rules
and regulations pe ' ' g to the responsibilities of the ORC as set forth in 15A NCAC 08G .0204 and failing to an result in Disciplinary
ions y the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in ,CJResponsible/Charge (BU ORC) / `
Print Full Name: CCt ke Je b., er !Ro A C Email: WW%-? OR(& SRO Gv <///ic (..)/1/l
Certificate Type / Grade / Number: (A/�-Gi (� -
IO/122 Work Phone #: 6C2 9J 9 32
Signature:
Date: 7/o p2/
"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 BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email the
original to:
Mail or fax a copy to the
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Email: [e-mail]
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Fax: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Hanes Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 05-2015