WQ0004270_Other Agency Documents_20211013

RECEIVED/NCDEQ/DWR
WATER POLLUTION CONTROL SYSTEM OPERATOR:DESIGNATION FORM (WPCS CC)
OCT 13, 2021
Permlttee Owner/Officer Name:
Mailing Address:
City:
Email Address:
Facility Name:
County:
Signature:
A 13, (
NCAC 15A 8G .0201
Press TAB to enter information
'ri+ .r' t21- 41
Phone:
State: ill L - Zip; Z
*r, Co w%
WOROS
?OiESVILLE REGIONAL OFFICE
Date: to -13 -a/
Perndt# t l 6,9 q250
YOU MUST SUBMIT A SEPARATE FORM FOR EACH TYPE AND CLASSIFICATION OF SYSTEM:
Facility Type:
Facility Grade:
Seteet WWI i41441/4' f:6 -3-14144,
select Ww I SI
OPERATOR IN RESPONSIB CHARGE (ORC)
Print Full Name: Ck ks L La's
Phone: t _r s l " p y�
Certificate Grade: Select Certificate t 6t1.1213..tcgioLjexo leg
Certificate Type: Select OIL) ST
Email Address: & .j 60 or:
Signature:
"certify that 1 agree to my designation as the Operator in Responsible Charge for the facility noted. 1 understand and will abide by the
roles and regulations pertaining to the responsibilities of the ORC as set forth In 25A NCAC OSG .0204 and failing to do so can ,result In
Disaplrnory Actions by the Water Pollution Control System Operators Certification Carnmissiare'
Effective Date: /O-1.a " Z I
BACKUP ORC
Print Full Name: Work Phone: q - Met- f jC(
Certificate Type: Select ijo I 51_ Certificate Grade: SeieCt j Certificate #: I,01,1 /QFt0i$ -
Email Address:
Signature:
'7 Certify that 1 agree to my designation as a Backup Op • for In Responsible Charge for the facility noted_ t understand and will abide by
the rules and regulations pertaining to the responsibilities of the ORC as set forth in 2S4 NCAC 08G .O204 and foiling to do 50 can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission.',
j — Effective Date: raj-i g-LJ
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Fax:[phone]
ORIGINAL to: Raleigh, NC 27699-1618
Mail or Fax
a to:
Asheville
2090 US Hwy 70
Svrannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fa yettev lie
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Faso 910486-0707
Phone: [phone]
'A llndngbon
127 Cardinal Dr.
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 Mall Rd.
Winston-Salem, NC27205
Fare 336-776-9797
Phone: [phone]
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]