NC0044725_Operator Designation Form_20070119

Water Pollution Control System ORC Designation Form
WPCSOCC
NCAC 15A:08G .0201
General Information:
Permittee Owner/Officer Name:
I..owri v1130-Mcoxl-en A: r rar'�'
Mailing:Address: k(o1Dt Airport- (Z�.:
City: Mo.+f
State: NG Zip: 28 36
Telephone Nuinber: ( 10 )
Signature:
.Facility Information:
Facility: Lau V.),,r9-Mo.x.ivr• A6r (4
Permit Number: 14G BO I-1M-1-I z S County: S moo-}- ms:;c1
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM !
Mark (X) Type of Facility Class (1- 4)
Class
Wastewater Plant x gray Irrigation N/A
Physical/Chemical Land Application N/A
Collection System Subsurface N/A
Operator in Responsible Charge:
Print Name: Social Security # :
'Certificate Type and Grade: Certificate #:
Work Telephone: ( ) Signature:
Back -Up Operator in Responsible Charge:
Print Name: avtA s vav4o.Azai1
Certificate. Type and Grade: 'W 1nf 3
Social Security # : 'Z2g -lob - S 35 G
Certificate #: 9 g .to 5 0 5
Work Telephone: (910 ) a H '4 - 5,0 Signature:
Mail or Fax to:
WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]