NC0061719_Operator Designation Form_20121210

Dec 12 2012 7:12AM Aqua NC 9108671327
page 2
Water Pollution Control System OperatorDesignation Form
WPCSOCC
NICAC 15A SG .0201
Permittee Owner/Officer-Name: Ti,nnvas 1. tknhert-s 1''1 )49r).
Mailing Address:Air?.1Yi�Jrriy,ai�
City: :P13r•3
State: Al G. Zip: ? 75! 1 -
Email address:.- I rl'kERT•- P. 1s DAjR
Signature.
Phone #: (lief V-11.; -
Date: \a`\`o `1.4'
Facility Name: 4h1'otjd1a ,P'4JTP. •Permit#: 1JC,DDto11.1'q
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Tyne/Grade:
Biological WWTP .j( Surface. irrigation
Physical/Chemical Land Application
Collection System
•
Operator. in Responsible.Charge (ORC)
Print Full YaTneTN (.l f}_ I 1.) i !
J.
Certificate Type /Grade / Number71ti141 19
Signature:
Work Pllone #: (cyf r )05--aei
(.
Date:. ie;2:- —- a
"I certify that t agree td my designation as the Qperator in Responsible Charge for the faci3ity. noted. I'understand and Wilt abide by the:rules'
and regulations. pertaining io •the responsibilitiesofthe ORC as Set'fbrth.in 15A NCAC•08G .0204 and failing to do so can et:soh:in Disoipl:niuy
Actions by•the Water ?dilution Control System Operators Certification Commission."
Back -lip .Operator, in Responsible :Charge(BU'ORC)
Print Full Name: at a„-•
Certificate Type / Grade /Number: Vel q?.q Work Phone#: ! ql 0,24 7^`c 7
Signature: ;u� ' `ror ram% e-d;e Date: �'
"I' certify that I agree to my designation as a Back-up Operator in Responsible Charge For the facility noted.] underrtand and Will abide•by the
rules and regulations pertaining to the responsibilities arthe BU ORC as set forth in 1.5A NCAC O8G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
•
Mail orfax the original to: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-161S Fax: [phone]
Mail orfax a copy to the Asheville
2090 US.Hwy 70
Swe:mance 28778
Fax: [phone].
Phone:-828.296.4500
appropriate Regional Office:
Washington
943 Washington Sq Mnit
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 2830'1.5043
Fax:910.486,0707
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 2S405-2845
Fax: [phone]
Phone; 9E0.796.7215
Mooresville
610•G'Center. Ave;
Salle 301
lvlooresvil!e 28115,
Fax::704:6634040
Ph inet .704.663.1699
Wiesttni-Selom
585 Wauglilown SI
Winston-Satern 27107
Fax:336.771.463I
Phone: 336,771.5000
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax; 910.571.4718.
Phane919:791.4200
Revised 1 0 2012

Water Pollution Control System Operator Designation Form
wPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Nance: i (71.c , ll £' $ Q� .
Mailing Address:
City: Rt)in_S
Email address:
Signature:
State: n% Zip: ,9 7c QL
Phone #: ('it )
0, tP -C.cA . (1 nays
Date: /2./
Facility Name: _off a n ' ty juS
Permit #: /l4(. b0 (r 5e.8 j
SUBMXT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Tyne/Grade:
Biological WWTP ci Surface Irrigation
Physical/Chemical Land Application
Collection System
Operator in Responsible Charge (ORC)
Print Full Name: iThrr w-v (; k� �
Certificate Type / Grade / Number: Cz) 01 q 7 5 i3 Work Phone #/: (a 1)
Sigrlatu� �x�'ll Date: / 02, - I f — ;o t
"I certify that I agree to my designation as the Operator in Responsible Charge for the facility noted. I understand and will abide by the rules
and regulations pertaining to the responsibilities ofthc ORC as set forth in I5A NCAC 08G .0204 and failing to do so can result in Discipline y
Actions by the Water Pollution Control System Operators Certification Commission"
Back -tip Operator in Resp nsible Char (BU ORC)
Print FunI Name. 1'-/ €91 1v (�.(i'< JP
Certificate �y�_, , de / umb
Signature.
Work Phone #: 9iQ ) j "" q. 0
Date: I1— cRC — v l
"I certify that I agree to my designation as • e ack-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 ]1U ORC as set forth in 15A N CAC 080.0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Conuuissiou_"
Mall or fax the origuurl to: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 Fax: [phone]
Mail or fax a copy to the Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: [phone]
appropriate Regional Office:
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington •
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone [phone]
Mooresville
610 E Center Ave
Suite 30]
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
585 Waughtown St
Winston-Salem 27107
Fax: [phone]
Phone: [phone]
Raleigh
380013arrett Dr
Raleigh 27609
Fax; 919.571.4718
Phone:[phone]
Z00/300.d 60004
d1Mi 8NI880d
Revised 10-2012
630E81760LS '61.0V L/ZL

, Dez 12 2012 7:12AM .Aqua NC 9108671327 page 1
AQUA
North Carolina.
Aqua North Carolina
6902 Sandridge Dr.
Fayetteville, NC 28314
FACSIMILE TRANSMITTAL SHEET
To: JPC.SDCC.
is 910.779.0794
F: 910.779.0796
From: Alley1a.n�PlS
Company: Avo. MP
Date: 1Z-1Z4Z.
Total Number of Pages Including Cover:
Comments:
CRC Desi3nort-ion Form far h)ocalake IJ)TP
Va55, A.1 f