NC0026921_Operator Designation Form_20140926

09/29/2014 11:32 9108589808
TOWN OF PARKTON
PAGE 0110.2
Town of Parkton
28 West David Parnell St./ PO Box 55
Parkton, NC 28371
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Attention:
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Fax Number
FAX COVER SHEET
Phone: [phone]
Fax; 910-858-9808'
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•'09/29/2014 11:32 9108589806
TOWN OF FARKTON PAGE 02 / i02
Pe>nuittee Owner/officer Name:
Mailing Address: P 0 :15 x 5' 5
City: RID- `.-A0 tA- State:' Zip: cg,q r7 t—
Signature:
Water Pollution Control System Operator Designation Form
wresocc
NCAC 15A 8G .0201
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Q� ITCH
Phone #: (`r) O) 5 Chi — 3 3(..,
0
Date: -1 /(g( f 'f
Facility Name; Q � c7 t'1 L°j W T P
SUBMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM
Facility Type & Grade:
Biological WWTP
Physical/Chemical
Collection System
Permit #: (caq A 1
//��
County: 1Io106 50 a
Type .Grade Type Garde
Surface Irrigation
Land Application
N/A
Operator in Responsible Cbarge (ORC)
Print Full Name: i c Th Vj E4v.3 CA, Ca i.r
Certificate Type] Grade / Nunalber: V\I W c (U (06 a` Work Phone #: (9 I 0 ) W5 ? - 3 ,3 (a0
Signatures:
Date: l /3(( (``-
"I certify that X agree to my designation as 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 Folltition Control Systern Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name:
Le,r ue.,l L..,oJulex'
Certificate Type / Nuxu r: Ui 1'J, . a-tr ``7
Signature:
Work Phone #: (61 I G) 1 ' J 5 I
Date: c ( (4-
"I certify that I agree t6my 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 BU ORC as set forth in 1SA NCAC 08G .0205 and failing to do so can
result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail 2e Fax to; WPCSOCC
1618 Mail Service center
Raleigh, NC 27699-1.61.8
Fax:[phone]
(See next page for dcaiguatiou of additional back-up operators. Designation of more than One back-up operator is optional.)
Revised 8-2007