WQCS00144_Operator Designation Form_20210727

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10:17:32 p.m. 07-23-2021 1 /1
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
N€AC-1SAtG- 0201
Permittee Owner/Officer Name:
Email Address:
Press TAB to enter information
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Permittee Signature:
Facility Name: Town 6 Mr. Son
Date: 7 i 7 -- 2 /
Permit # 1,N) Q(, S 001119
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: SELECT ONE
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Justin Shawn Frazier
Certificate Type: WW ID Certificate Grade: II El Certificate #:
Email Address: [e-mail]
Signature: /� '� Effective Date: 7 - Z 7 - 2 r
336-501-0982
1008923
"1 certify that I agr'- to my designation as 4'e 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."
Print Full Name: John Anthony Shuff
Certificate Type: WW Certificate Grade: IV
Email Address: [e-mail]
Signature:
Work Phone:
Work Phone:
Certifirjtp #;
336-591-7852
9$7Q76
r� 1(1 — -ix
"1 certify that 1 agree to ki y 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."
Effective Date: 7 - Z 3 - zt
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. 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-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]