WQ0034380_Operator Designation Form_20210729

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PCsO
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P.Q. BOX 98 / 127 FLYNT ROAD
LAUREL, MS 39440
601,649.4030
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94.
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC) F4
NCAC15A8G.0201 eo
41,
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44,4,4
s46/4/ /rem ea
Date: 7Z/)I
Press TAB to enter Information
Permittee Owner/Officer Name: Pawl Billingsley
Email Address: [e-mail]
Permittee Signature:
Facility Name: Sanderson Farms - Kinston Facility
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: SI
Print Full Name: Randy Clark
Certificate Type: SI al Certificate Grade: Select IN Certificate #: 996273
Email Address: [e-mail]
Effective Date:
Permit #
W00034380
91 0-674-6574
Signature:
certify that f agree ro my designation as the 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 086 .0204 and failing to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Work Phone:
Print Full Name:
Certificate Type: Select
Email Address:
Certificate Grade: Select
Work Phone:
Certificate #:
Signature Effective Date:
1 certify that I agree ro 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 ogG .0204 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email
ORIGINAL to:
Mail or Fax a COPY to:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27599-1618
Email: [e-mail] Fax: [phone]
Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fa�7 ;,,252-975-3716
Phone; 252.946-6481
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 11/2020

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A SG .0201
Press TAB to enter information
Permittee Owner/Officer Name: Paul Billingsley
Email Address: pbillingsley©sandersonfarms.com
Permittee Signature:
Facility Name: Sanderson Farms - Kinston Facility
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: WW-IV
Date: x/A
Permit # WQ0034380
Print Full Name: Randy Clark
Work Phone:
910-674-6574
Certificate Type: WW MI Certificate Grade: IV 31 Certificate #: 22332
Email Address: rclarkL'7u sandersanfarms.com
Signature:
"1 certify that i agree to my designation as the 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 ISA NCAC 0$6 .0204 and foiling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Effective Date:
Print Full Name:
Work Phone:
Certificate Type: Select Certificate Grade: Select Certificate #:
Email Address:
Signature:
Effective Date:
"( certify that 1 agree to my designation as a Back-up Operator in Responsible Charge far the facility noted. 1 understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in 25A NCAC O8G .0204 and foiling to do so con result in
Disciplinary Actions by the Water Pollution Control System operators Certification Commission?
Mail, fax or email
ORIGINAL to:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Email: certadmir )ncdenr_gov Fax: [phone]
Mail or Fax a COPY to: Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax:[phone]
Phone: $28-296-4500
Washington
943 Washington Sq. 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 Or.
Wilmington, NC 28405-2845
Fax: [phone]
Phone:[phone]
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax; 704-663-6040
Phone: [phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
RoAted 1112020