NC0004944_Other Agency Documents_20210811

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
Permittee Owner/Officer Name:
Email Address:
Permittee Signature:
6-
NCAC 15A 8G .0201
Press TAB to enter information
Salisbury investments 1 LLC/ Greg Coleman
dreg a(�forsitein or)
Facility Name: Edge Water Treating, LLC
SUBMITA SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: N/C
RECEIVED/NCDEQ/DWR
AUi] 112021
WOROS
MOORESVILLE REGIONAL OFFIrF
Date:
Permit #
C_S-z° (
NC0004944
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Nicholas James Merwin
Certificate Type: ct Certificate Grade: 6 lect
Email Address:
Signature:
[e-mail]
Work Phone:
Certificate #:
Effective Date:
704-213-2309
1006823
"1 certify that / agree to my designation as the Operator in Responsible Charge for the facility noted. / 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: Braden Joshua Cook
Certificate Type: Wct
Email Address: brad
Certificate Grade: Relect
ook • e.schariotte.com
Work Phone: [phone]
Certificate #:
1002815
Signature: t +� Effective Date: 't 2.2 2.
"/ certify that / agree to y designation as a Back-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 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."
Mail, fax or email
ORIGINAL to:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Email: v?rtad ,n(q-ncdenr.g v Fax: [phone]
Mail or Fax a COPY to: Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
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 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 11i2020

Facility Name: Edge Water Treating LLC
Page 2
Permit #: NC0004944
BACKUP ORC
Print Full Name: Kimberly Dawn Holt Work Phone: [phone]
Certificate Type: Select Certificate Grade: I5irlect
Email Address: kim.holt(aepscharlotte.com
Signature: k.14k-- C-) %-t- Effective Date: 7- ZO
"I certify that I agree to my designation as a Bock -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 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."
Certificate #: 993802
BACKUP ORC
Print Full Name: Kellie H Hedisk earl (<
Certificate Type: 16ct
Work Phone: [phone]
Certificate Grade: I$elect Certificate #: 1005640
Email Address: kelliiedrickAepscharlotte.com
Signature:
7
"/ certify that I ogreeiocnd signation as a :ack- . operator in Responsible Charge for the facility noted. / 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:
Certificate Type: Select
Email Address:
Certificate Grade: Select
Work Phone:
Certificate #:
Signature:
Effective Date:
"I certify that i agree to my designation as a Back-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 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:
Certificate Type: Select Certificate Grade: Select
Email Address:
Signature:
Effective Date: `7(2c' 2
Work Phone:
Certificate #:
Effective Date:
"1 certify that l ogree to my designation as a Back-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 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."
Revised 11/2020