NC0062278_Other Agency Documents_20210927

RECEIVED/NCDEQ/DWR
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (wpcsoery 2021
NCAC 15A 8G .0201
Permittee Owner/Officer Name:
Email Address:
Permittee Signature:
Facili
Name:
Press TAB to enter information
Date:
WQROS
MOORESVILLE REGIONAL OFFICE
Kt 11,,
g 10CDEQ/DWR
SEP 2 7 2021
WQROS
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASS F CATION: SELECT ONE MOORESVILLE REGIONAL OFFICE
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name:
Certificate Type: Select U) I,..) Certificate Grade:
Email Address: j rab1IOw,
elect j
Work Phone:
70'!-3s 1-goy/
Certificate #: , iJll'7rh
Signature: Effective Date: 9(3 - Z 1
"I certify that l agree to my designation the 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: gi- 1'O 11 cr) S Work Phone:
T
Certificate Type: Select W W Certificate Grade: Select T. Certificate #: f0I612S'
Email Address:
to -3
nor
Signature: f ��t` ,t. Effective Date: 9— ig - t i)
"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 falling 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,
618 Mail Service Center, Raleigh, NC 27699-1618
Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5
Fax: [phone]
Phone: [phone]
Mooresville
610 E. Center Ave., Suite 301
3 Mooresville, NC 28115
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
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 it/2m

September 21, 2021
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Delegation of Signature Authority
BERKELY OAKS WWTP
NPDES Permit Number NC0062278
To Whom It May Concern:
AECEIVEDINCDEQ/DWR
SEP 2 7 ?P ii
WORO6
fRl LF REGi:ONRL OFFICE
By notice of this letter, I hereby delegate signatory authority to each of the following individuals for all
permit applications, discharge monitoring reports, and other information relating to the operations at
the subject facility as required by all applicable federal, state, and local environmental agencies
specifically with the requirements for signatory authority as specified in 15A NCAC 2B.0506.
Individual #1
Individual #2 (if applicable)
Name:
Title:
Mailing Address:
Charles Brandon Long
Owner - Tcw Wastewater
5600 Lakeview Road
Charlotte, Nc 28269
Physical Address:
(i, f djerent)
Email Address:
Office Phone:
Mobile Phone:
N/A
[e-mail]
704 - 351 - 4049
704 - 351 - 4049
If you have any questions regarding this letter, please feel free to contact me at Enter Email or Phone
Number.
Sincerely,
Adam Minnick
Manager, Stonetown Berkley Oaks, Llc
720 S. Colorado Blvd., Suite 1150n
[e-mail]
303-407-3002
cc: Mooresville Regional Office, Water Quality Permitting Section