NC0027103_ORC Designation Form_20170802

JG/ 02/2017/WED 10:11 AM Town of Pembroke
FAX No, 910210472
P. 001/001
.Eerm.ittee Owner/Officer Name:
Mailing Address:
city: et.wb roles
Email address:
Signature:
Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
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State:iiC Zip: Z,
Phone #:
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Date:
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fro ' % 7 - gen
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Facility Name:
pl 6rak WAett�'ur; f 1-/
County: goy --<$..0-
Permit #: /V2 06 2-7 / o ?
Biological
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM:
Facility Type/Grade (CHECK ONLY ONE);
Collection Pb.ysical/Chetnical Surface Inzgation Land Application
Operator in Responsible Charge (ORC)
Print Full Name: eto v i ELM` i �('.CS %
Certificate Ty / Grade / Number: tilAd/431A 0180 PI
Signature:
Emaii: Vtlt n 0 106,49(o e• i'4e , Cosr'1
Work Phone i910%-6o ] • (9
Date: 'J " ! " )7
"I certify that 1 agree to my designation as the Operator in Responsible Charge for the facility noted.l understand and will abide -by the rules
and. regulations pertaining to the responsibilities of the CRC as set forth in 1.SANCAC 08G .0204 and failing to do so can result in Disciplinaty
Actions by the Water Pollution Control System operators Certification Commission."
Back -Up Operator in. Responsible Charge (BU ORC)
Email:
Print .Full Name:
Certificate T Grade / Number: W Work Phone #:
Signature. /[ Date: 7 02 / / 7
•
"1 certify that 1 agree to zxiy designation as a Back-up Operator in Responsible Charge for the facility notcd.l understand and will abide by the
rules and regulations pertaining to the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission-"
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Mail, fax or email tize
original to:
Mail or fax a cnmT to the
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center, Raleigb., NC 27699-1618
Email: certadmin(alncdenr.eov
Asheville
2090 US Hwy 70
Swanr:,anoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: 910A33.3300
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: 910,350,2004
Phone: [phone]
Fax: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
450 W. Haile, Mall Rd
Winston-Salem 27105
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax.: [phone]
Phone:[phone]
Revised 05-2015