NC0062855_Operator Designation Form_20101201

Jan. 3, 2011 2:28PM
No, 8516
Water Pollution Control System Operator Designation Form
WFCSOCc
NCAC 15A 8G .0201
Permittee Owner/Officer Name: c"1 k) .i eF fr.isi„f_5
Mailing Address: Pi i &I X a. 14,
City: AbkinS State: PC Zip; 27.30E - Phone #: (`liD) c % - y3 /
Email address: r 0 ).- ; ltit kli. k d e w. to eor 1. c o vk
Si atttre• —WV ;AVAlertS1C__,
Facility Name:
' bki ns__ w w 7-P
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM !
Facility Type & Grade:
Grade
Grade
Date: i 2,- ! l O
Biological WWT? - r Surface irrigation N/A
Physical/Chemical Land Application N/A
Collection System
Permit#: /4)606 a$,53--
RECEIVED
JAN 0 3 2011
DENR -FAYETTEVILLE REGIONAL OFFICE
Operator in Responsible Charge (ORC)
Print Full Name: Kt, d11 tl
Certificate Type / Grade / Number: - /And L ` cf s 4 1-1' I Work Phone #: (31 O t ird 30 63
Signature: �4 l Date: 1 i
"I certify that 1 agree to my designation as the Operator in Responsible Charge for the facility noted. I lmderstand 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"
Back -Up Operator in Responsible Charge (MI ORC)
Print Full Name: C7e le ""f : N a y eAtel
Certificate Type / Grade / Number: 14 ha q R S 34 I Work Phone #: (/0) `l q � q 1
Signature: >21.2d1 k Date: IV- - - _ - -
"I certify that I agree to my designation es a ck up Operator in Responsible Charge for the facility noted. I imdctstand and will abide by the rules
and regulations pertaining to the responsibilities of the DU 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 Cetti4cetion Commission."
(a119E Fax to; WPCSOCC
1618 Mail Service Center
Raleigh, NC 27699-1618
Fat: 919/733-1338
.(See next page for designation of additional back-up operators. Designation of more than ono back-up operator is optional.)
Revised 1-2010