NC0050661_Other_20211018

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Water Pollution Control System Operator Designation Form
wpcsocc
NCAC 15A 8G .0201
Perinittee Owner/Officer Name: I A 113s a r* a r► - ego, o r
Mailing Address: PO 'SOX I BS
City: Nuale,sc ;etai State: NC. Zip: 278(ey- Phone#: 2S2- B2.Z-44$Z3
Email address: C-inuctC 30 C7 ew►ba.r9 vrrw. 1 . COmA
Signature:
Date: / — o7 tr -440
Facility Name: Tet.rin n. 0I les;'lefol
County: Ea; beta wt lne
Permit #: / /4.410 V to& t
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade (CHECK ONLY ONE):
Collection Physical/Chemical Surface Irrigation Land Application
Operator In Responsible Charge (ORC)
Print Full Name: Email:
Certificate Type / Grade / Number: Work Phone #:
Signature: Date:
"I certify that I agree to my designation as the Operator in Responsible Charge for the facility noise, I understand and will abide by the rules
and regulations pertaining to the responsibilities of the ORC as set forth in 1SA NCAC 080.0204 and failing to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU ORC) �--L"�
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Ocu-10 S W it i� � i i` R w15 Email) Cq 1-1u j i,J t t l dt'M $•_ � q (� r C W 6%5 Ka 11, eC
Print Full Name:
Certificate Type / Grade / Number: d qg - 4 ci Work Phone ir#: 2 52 - - 3 7 3_
Signature: Date: 7 `2? -.2.
"I certify that 1 agree to my designation es 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 I1U ORC ae set forth in 15A NCAC 09G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission,"
Mail, fax or email the
adsiilat
Mall or fax a on to the
appropriate Regional Ofjlce:
W1'CSOCvC 1618 Mail ServGice Center, Raleigh, NC 27699-1618 Fax: 919.713,2726
F .�ry. « 1. .t �
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: 828.299,7043
Phone; 828.296.4500
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone: [phone]
F aysttevilie
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: 910.330,2004
Phone: [phone]
Mooresville
61C E Center Ave
Sui:e 301
Mooresville 2l1115
Fan: 704.663.6040
Phone: [phone]
Winston-Salem
45C W. Hanes Mall Rd
Winston-Salem 27105
Feat 336.776.9797
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 05-2015