NC0040011_Delegated Authority_20210923

From.Town of Yancayvulle
1-0.919195714718
09/23/2021 21.23 *042 P.001
Nc WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORMt f svrZOltai Quality
NCAC 15A 8G .0201
Press TAB to enter information 2921
Permittee Signature:
Raleigh
Permittee Owner/Officer Name: i< Q,,Y-, aY i�v.70.-Y YNe Regi0tla1 off,.
Email Address: �rrn&nay_1r� E ya..rutj Vi ]Lp_ t JC- • G'A'j140 Mak' b:144110
Facility Name: Yanceyville WWTP
Date: C)4 - I t_, - 1
Permit # NC0040011
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: SELECT ONE
ORC - OPERATOR iN RESPONSIBLE CHARGE
Print Full Name:
Certificate Type: Select
Email Address:
Signature:
Certificate Grade: Select
Work Phone:
Certificate #:
Effective Date:
"1 certify that 1 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 1SA 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: Kevin Protus Wood
Certificate Type: WW El Certificate Grade: IV Q Certificate #:
Email Address: [e-mail]
Signature:
Work Phone:
336-442-5506
997819
Effective Date: oq / /4, / z i
"1 certify that 1 agree to 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 08G .0204 and failing to do so can result In
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mali, fax or email
ORIGINAL to:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Email: [e-mail] 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 0r.
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