NC0027103_ORC Designation Form_20040427

Apr 28 04 02:23p KAREN T. DIAL 910-521-2343
Fax
To: To: WPCSOCC
Town of Pembroke
POST OFFICE BOX 866
PEMBROKE, NORTH CAROLINA
28372
From: Rhonda Hagan Locklear
Fax: [phone]
Pages: 3
Phone:
_412
-04
Re: ORC Change
•
CC: Belinda Henson
Urgent
Recycle
0_,F.offieview 0 Please Comment ly El Please
• Comments:
The Town of Pembroke would like to change the ORC from Garry Harris to Rhonda Hagan
Locklear. Please add Jerry Brooks and Garry Harris as Back -Up ORC's.
Thank you,
Rhonda Hagan Locklear

Apr 28 04 02:24p KAREN T. DIAL 910-521-2343 p.2
•
Water Pollution Control System ORC Designation Form
WPCSOCC
NCAC 15A:08G .0201
General Information:
Permittee Owner/Officer Name:
Mailing Address:
City: r--7(fr cxL\y) S cAC L'. State: N C- Zip: Q
Telephone. Number: ( i G) S a l
Signature:
Facility Information:
Facility:
ate: ef7,4
Permit Number: N C. D) �, r) 103 County:
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM !
Mark (X) Type of Facility Class (1— 4) Class
Wastewater Planter Spray 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: n�f' 1^� oof f t 5 Social Security # : A 3 gC
Certificate Type and Grade: Certificate #:
Work Telephone: 01\— -a Signature: '7D
Mail or Fax to: WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]

Apr 2}8 04 02:24p KAREN T.. DIAL
910-521-2343 p.3
Certificate Type and Grade:' Lt Certificate #:
Work Telephone: (Ci1O) 5 2.\ " Signature:
hot
Water Pollution Control System ORC Designation Form
WPCSOCC
NCAC 15A:08G .0201
General Information:
Permittee Owner/Officer Name: Q-00' (\fil `
Mailing Address: 7 . ''
City: Ro m lU f 1�
State: Zip:
Telephone Number: ( CA16) 62 I - g
Signature: / / L — Date: 6
Facility.Information: R 9 'Y \b(e Q RS` ,c�, `'
Facility:
Permit Number:
County:
ooeszn
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM !
` Mark (X) Type of Facility Class (1 — 4)
Wastewater Plant
Physical/Chemical
Collection System
\G r.
Class
Spray Irrigation N/A
Land Application N/A
Subsurface N/A
•
Operator in Responsible Charge:
Print Name:�� �C (1 I(Z \\a ,n' . t)C��e Social Security # : a'WC) — 0'-``3
7- 3 4.-/
ko/c66-')
Back -Up Operator in Responsible Charge:
Print Name: \ zr (' 7`}c Social Security # : -=
Certificate Type and Grade:. i/VA c bl if�7-c� ?. Certificate #: , ( 9 -7 7
Work Telephone: (co ) Q k - Signature: k /26 i w
Mail or Fax to:
WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]

Apr 27 04 02:31p
KAREN T. DIAL
910-521-2343
P.
1
To: WPCSOCC
Town of Pembroke
POST OFFICE BOX 866
PEMBROKE, NORTH CAROLINA
28372
From: Rhonda Hagan Locklear
Fax: [phone]
Pages: 3
Phone:
Date: 4/27-04
Re: ORC Change
CC: Belinda Henson
0 Urgent
Recycle
view 0 Please Comment 0 Please Reply 0 Please
• Comments:
The Town of Pembroke would like to change the ORC from Garry Harris to Rhonda Hagan
Locklear. Please add Jerry Brooks and Garry Harris as Back -Up ORC's.
Thank you,
z 64- ei& ? G
Rhonda Hagan Locklear

Apr 27 04 02:31p KAREN T. DIAL
910-521-2343 p.3
Water Pollution Control System ORC Designation Form
wPcsocC
NCAC 15A:08G .0201
General information:
Permittee Owner/Officer Name: ('\t� e, Qu\' - Y)C-•S
Mailing Address: 0.
City: Rc mb i 1L e, State: @N C- Zip:
Telephone Number: ( U)) cj OR
Signature:
al'102
Date: 6 77 44r2
Facility Information:
Facility: R p e'Y\hrc .e .Ste
Permit Number: N 'ail 9' j I County:
diDezn
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM !
Mark (X) Type of Facility Class (1 — 4)
Wastewater Plant
Physical/Chemical
Collection System
X «1
Class
Spray Irrigation N/A
Land Application N/A
Subsurface N/A
Operator in Responsible Charge:
Print Name�� �C()C\ �C� 1�G .�n -OCL\ Social Security # : QUU r y\
Certificate Type and Grade: �w t��l�� ���\1 _�i�- Certificate #: D i' ( 3
Work Telephone: (Ci ) '3 a,` w ,;,q I Signature: P hY 1
Back -Up Operator in Responsible Charge:
Print Name: \ z 1- C' ��; v��r, Social Security # —
Certificate Type and Grade: tA,/q4_f
Work Telephone: (aqg`j Signature_ 70/2 //-
Mail or Fax to:
wPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]
Certificate #: 7
•

Apr 27 04 02:31p KAREN T. DIAL
910-521-2343 p.2
Water Pollution Control System ORC Designation Form
WPCSOCC
NCAC 15A:08G .0201
General Information:
Permittee Owner/Officer Name:
Mailing Address: .
City: ��yj 1 PEA(
C y w\c\c\\ncJ_,
S of
State: 0 C- Zip: Q
Telephone Number: ( '�' itj ) 5q1 - rirn p
Signature:
•
Date: 6 - 2% id3li
Facility Information:
Facility: ? Vrl'1 '' &Q
Permit Number: C (DU ' ) [u3 County:
! SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM !
Mark (X) Type of Facility Class (1 — 4)
Wastewater Plant
Physical/Chemical
Collection System
Class
Spray Irrigation N/A
Land Application N/A
Subsurface N/A
Operator in Responsible Charge:
Print Name: Social Security # :
Certificate Type and Grade:
Work Telephone: (__) Signature:
Certificate #:
Back -Up Operator in Responsible Charge:
Print Name:
Certificate Type and Grade:
Social Security # : 3 g C-%
1
Certificate #:
Work Telephone: ((kkj ) `a.`c) Signature: U\'
Mail or Fax to:
WPCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]