NC0061719_Operator Designation Form_20200102

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WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORMJAX rg )
NCAC 15A 8G .0201 u"
Permittee Owner/Officer Name:
Email Address:
Permittee Signature:
Facility Name: Woodlake
Aqua NC
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aquaamerica.com QFFfC€-
Date: / `1,
NC0061719
Permit #
SUBMIT A SEPARATE FORM FOR:EACH CLASSIFICATION OF SYSTEM: Facility Type: WW
Facility Grade: II
Print Full Name: James Williams Work Phone:
Certificate Type: WIN Certificate Grade: 'II Certificate #:
Email Address: JGWilliams@aquaamei ica;com
ORC - OPERATOR IN RESPONSIBLE CHARGE
9107836817
1009140
� -Signature: �' c�= 'f%:` :..� .._:� �;r �, .
Effective Date { <:._ t✓ ,'
"1 certify that 1 agree to my deslgnaton"as the Operator In Responsible Charge for the facility noted. 1 understand and will abide by the
rules and:regulatlons pertaining to the responsibilities of the ORC asset forth in'1SA NCAC 08G .0204 and failing to do so can resent in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
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ti
Print Full Name: Scott McMaster
BACKUP ORC
Certificate Type: WVV
Certificate Grade: i
Email Address: SAMcMasteri aquaamericpcom
Signature:
- Effective Date: ,,
"1 certify that I agree to my designation as a Backup Operator in Responsible.Charge for the facility noted. 1 un tb� abide by
the rules andregidations pertaining to the responsibilities of the ORC as set forth in .15A NCAC 086' .0204 and foiling to do so con result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
ORIGINAL to:E nail:` 'ti ' Fax:[phone]
:Work Phone: t 91 67281043
Certificate .#: 1009188
Mail or Fax a COPY to: Asheville
2090 US Hwy 70
5wannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington.
943 WashingtonSn. 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.
WI Irrmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite j01
Mooresville, NC 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
45:W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone
i
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC.27609
Fax.[phone]
Phone: [phone]
Retdsed 5'2019

Facility.•Name: Woodlake
Page 2
Permit #: NC0061719
BACKUP ORC
Print Full Name: Nathan Schnatter
Work Phone: [phone]
Certificate Type: WW Certificate Grade: t "
Certificate #:1QR8616
Email Address: [e-mail]
Signature:
q }
Effective Date: (/ 1 / 2 Z
"1 certify that l agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I and ,rstand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth In 15A NCAC 08G .0209 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Christopher Collins
Certificate Type: VVW Certificate Grade:: IV Certificate is: 9951621
Email Address: [e-mail]
Signature: W� Effective Date: /—
"! certify that l agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. l and" rstand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC O8G.0204 and failing'to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
L
BACKUP ORC
Print,Fuli Name: Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature:
Work Phone: [phone]
Effective Date:
'7 certify that 1 agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. 1: 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."
BACKUP ORC
Print Full Name: Work Phone
Certificate Type: Select Certificate Grade: Select Certificate#:
Email Address:
Signature: Effective Date:
"I certify thatl agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. i unc rstand and will.abide by
the rules and regulations pertaining to the responsibilities of the-ORC as set forth in 15A NCAC 08G .0204 and faiting:to do so can result ip
Disciplinary Actions by the Water Pollution Control Systerri Operators Certification Commission."
Revised 5✓2019