NC0061719_Operator Designation Form_20070618

Water Pollution Control System Designation Form
General Information:
WPCSOCC
NCAC 15A:08G .0201
o -k- Li 0 b' `l-'l- (•.;ar ^v < WA A r.
Permittee Owner/Officer Name: Q �t rc �/ U_A- e_ 5 ,� no .
Mailing Address: A), l O Li e.,/ L� .3 t?i
J
City: State: lyc C- Zip: 1 J I , -
Telephone Number (C1 (0l) t - i Fax Number (c (Ci) (1, O I
Signature: 1/„j
Date:
Facility Information: �,
Facility Name: 1 ;lla\>d (C ,Le t✓Vi l'r't� �'v; 0-1 L,LL')
Permit Number: l l C_ D (, 1 -] 1 Cj County:
DOv L
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM !
Mark (X) Type of Facility Grade Mark (X) Type of Facility
Wastewater Plant Spray Irrigation
Physical/Chemical
Collection System
Land Application
Operator in Responsible Charge:
Print Name: •��Qr r \ r Ana(-5 i -\ ( "
Certificate Type and Grade: l,1' \,V L
Work Telephone: (.J-)- ()oSignature:
Back -Up Operator in Responsible Charge:
Print Name: l'l�—h 1�1 lr l`1 �? a'lail
ertificate A :
11
Certificate Type and Grade: 1,0 lft� �� Certificate 4: �6-1 D
Work Telephone: ((-(c-1 00 Signature:v�l�s
Mail or Fax to:
WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]

Permit Number: D' CO l ] 1! Page 2
o,Op01 e_oLL�- V
Back -Up Operator in
Responsible Charge:
Print Name: �, 11 \ i a -try\ Lei-iY1 1'V1
Certificate Type and Grade:
Certificate #:
Work Telephone: ( ,)) L(c 00 Signature:} 4k, '
Back -Up Operator� in Responsible Charge:
atI Print Name: I YYk D -�-k L( k 0 vv-i e S
Certificate Type and Grade:
L)Li) - 11,L
Certificate #: Cl ') %,),
Work Telephone: (: -5 -) "D 3J ~ 4 or DSignature: 4y
Back -Up Operator in Responsible Charge:
Print Name: fAvACLiiL ) • L1iL
Certificate Type and Grade:
Work Telephone: ( ) �- 5 J - L{ 6l lD O Signature:
Certificate #: �J; • 1
Back -Up Operator in Responsible Charge:
Print Name: V(R.-`i- k 1 CVIA; \---\ r1 Tii -!1
Certificate Type and Grade: Li) L3
L
Certificate #: j
Work Telephone: (Q S a) 3 - fG Signature: -1 JVY�,,----
Back -tip Operator in Responsible Charge:
Print Name: L7 o le
Certificate Type and Grade: �� L) —
Certificate #: C el U5
Work Telephone: (cJ-3-) - DO 'Signature: j �i' Lt

Permit Number: C-DD t 1 k
L Dice � �Y_ ��t L fl 4 V4 Cl
Page 3
Back -Up Operator ih Responsible Charge:
Print Name: � �� 1^, I V/
Certificate Type and Grade: ,t) tip I Certificate R: -35-3
Work Telephone: (- 1-4'6; DD Signature:
Back -Up Operator in Responsible Charge:
Print Name: l i 0.-ivA r
Certificate Type and Grade: t.„,C\, ) -�
Work Telephone:. (�-SJ .6- (/ r ">.=)
p J ' `t U Signature:
Ce ficate #: 3-1
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Back -Up Operator in Responsible Charge:
Print Name: 6-L.y
Certificate Type and Grade:
a, r taulre
1
Work Telephone: (U 0 Signature:
Certificate 4: q4 i
7d r4r `',/�.s-
Back -Up Operator in Responsible Charge:
7 rr
Print Name: ,Ov..c,s Cn.- I`J u���� r C
Certificate Type and Grade: L.)Lod _ /Certificate m: C �,(� 3
Work Telephone: (c),S,)-) D- 6 - L)Q Signature'
Back -Up Operator in ``Responsible Charge:
Print Name: 1 0..-I( C r'41
Certificate Type and Grade:
Certificate 4: a L l I
Work Telephone: (.� J.) a �J5' L('1 0 V Signature: