NC0061719_Operator Designation Form_20070516

Water Pollution Control System Designation Form
WPCSOCC
NCAC 15A:08G .0201
General Information:
Permittee Owner/Officer Name:
Mailing Address:
City: Cc - 1.
j
Telephone Number (
Signature:
�I)
b va ui t ,r `---i g g i
State:. t C . Zip: -7J`—I g -
`i-(p 7 - 81 6., Fax Number (J 14 — J `%
Date:
57/6/0 7
Facility Informa'tion: 1
Facility Name: W O DA % ct
Permit Number: M ' - OD (.p / .1 1 C
County: OD e_
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM !
Mark (X) Type of Facility Grade
Wastewater Plant
Physical/Chemical
Collection System
Mark (X) Type of Facility
Spray Irrigation
Land Application
Operator in Responsible Charge:
Print Name: V-V. r y J arn 5 Coo IL-) 7i
Certificate Type and "Grade: - W — , lv Ce, ificate #: LSa % D
Work Telephone:..(a5 a) 35 D Signature:
Back -Up Operator inResponsible
Charge:
Print Name: P- 1/1 h o v ► . i3r-a_/1
l�w
Work Telephone: ) a 35 -.tip 00 . _SignaturL
Certificate Type and Grade:
Mail or Fax to:
WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Certificate #: (' a (P .0
Fax: [phone]
Vz-

Permit Number:
oNv1�t°�
Page 2
Back -Up Operator in Responsible Charge:
Print Name:
1 ri Q.rv, La_ m v v
Certificate Type and Grade: lyJJ - , Certificate #: I I / 9 3
Work Telephone (oa5 ) lt' (' 00 . Signature:
Back -Up Operator in Responsible Charge:
ra
Print Name: 1 ► 1 U-{ v T, 1--1 !1L l l ( c4-,"-
Certificate Type and Grade: 1 J L — Certificate #: c-3 D-3 7
Work Telephone: (asa) P.-3s-- Le g 00 -Signature:
Back -Up Operator. in Responsible Charge:
Print Name:
h 4 'hp e-✓ ��e_1e
Certificate Type and Grade:
LJ —IL
Work Telephone: (aka) 13S qg DO Signature:,
Certificate #: —( ? 9 S 1
n / -
Back -Up Operator in Responsible Charge:
Print Name: 3-0 h r' l3nl`
Certificate Type and -Grade: Uj.
Certificate #:
Work -Telephone: O5 a) L-% e% 00 Signature: -�
Back -Up Operator in Responsible Charge:
Print Name: W ; 1 o Q MTr- rr, ✓
Certificate Type and Grade: L L) 1 I
Work Telephone: ( ) Signature:
35-5
Certi e #: a— 3 O `4