NC0004944_ORC Form_20210823

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
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Permittee Owner/Officer Name: Salisbury investments 1 LLC/ Greg Coleman
Email Address: greg a(�forsitein or
Permittee Signature:
Facility Name: Edge Water Treating, LLC
SUBMITA SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: N/C
RECEIVED/NCDEQ/DWR
AUi] 1 1 2021
WOROS
MOORESVILLE REGIONAL OFFIrF
Date: C 620/ c,I
Permit # NC0004944
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Nicholas James Merwin
Certificate Type: ct Certificate Grade: Ulect
Work Phone:
Certificate #:
Email Address: [e-mail]
Signature: ,Ls Effective Date:
704-213-2309
1006823
"I 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
Work Phone: [phone]
Certificate Grade: Relect Certificate #: 1002815
Email Address: bradn.cookschariotte.com
Signature: Effective Date: rl2
"/ certify that / agree to n 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:
Mail or Fax a COPY to:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Email: v?rtadm,n(q-ncdenr.g v Fax: [phone]
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
Email Address:
Signature:
Certificate Grade: I5irlect
kim.holtepscharlotte.com
r
Certificate #: 993802
Effective Date:
"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."
BACKUPORC
Print Full Name: Kellie H He -disk e
Certificate Type: 18ct Certificate Grade: I$elect
Email Address: kelliiedrick anepscharlotte.com
Signature:
"I certify that I ogre e tocn c esignation as a1Back perotorin 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
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:
7
Work Phone: [phone] S 1
Certificate #: 1005640
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