NC0061719_Operator Designation Form_20190713

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Permittee Owner/Officer
Press TAB to enter information
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Mailing Address: De) (Y?Od('e,i(a, / £i'1
City: i..
Email Address: Ci4e.01A2re
Signature:
Facility Name:
Woo LaJtp
County: m Cirn2€
State:
fJA
Phone:
Zip: 0 7) SSW
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Date: /- - 4
Name:
Permit # 10'9
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type:
Facility Grade:
R SPONSIBLE+CHARGES{OItC)
Print Full Name: 1�f/Z ` . ... 11D-0.??C-7-17q
�h �►� �n��a � ��I ► in[ S 'Work Phone: Q
Certificate Type: W f1✓ - Certificate Grade:_,_j�L Certificate #: Qqq f
Email Address: M4CoiliAtsg a4 ,r1.(rG r( it
Signature:
Effective Date: 'l-/X--j q
"1 certify that 1 agree to my designation as the Operator in Responsible Charge for the facility noted. 1 understand and will abide by t
rules and regulations pertaining to the responsibilities of the ORC as set forth in 1SA NCAC 08G .0204 and foiling to do so can result
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Print Full Name: Michael Kevin Criscoe
CertificateType:
Email Address
Signature:
Wastewater
CA*wd rig
Work Phone:
Certificate Grade: IV Certificate #: 14 09 to
e Qa►-y\
Ili A-c-e
Effective Date: g " ly'/ i✓
"I certify that I agree to mdesignation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide 1
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 i
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email WPCSOCC, 1618 Mail Service Center,
ORIGINAL to: Raleigh, NC 27699-1618
Mail or Fax
a COPY to:
Asheville
2090 US Hwy 70
Swannanoa, NC 28778
828-299-7043 Fax:
Phone: [phone]
Washington
943 Washington Sq. Mall
Fax: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
910-486-0707 Fax: 704-663
Phone: [phone]
Wilmington
127 Cardinal Dr.
Ere alli'Ceft4dmin@pcdKr aov
Mooresville Raleigh
610 E. Center Ave., Suite 301 3800 Barrett Dr.
Mooresville, NC 28115 Raleigh, NC 27609 Fs
-6040 Fax: [phone]
Phone: [phone] Phone: [phone]
Winston-Salem
45 W. Hanes Mall Rd.