NC0026921_Operator Designation Form_20120713

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Water Pollution Control. System Operator Designation Form
W.PCSOCC
NCAC 15A. SG.1
.020
f
Mailing Address: PO 11? X 5 C
Permittee Owner/Officer Name:
City: I +.„,frie.._Lr • State: Zip: 21311 -
Email address:
Signature: „( ` /7.r1_
Facility Name:
' PAGE all/F�1
Phone #: (1.-D)
fah-7-1.
•
Date:
//02
Permit#: NC 63 Z.L92
SUB:MIT A. SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Type/Grade:
Biological WWTP j Suifaee Irrigation
Physical/Chemical Land .Application
Collection System
Operator in Responsible Charge (ORC)
Print Full Name:
r 1 q 7
Certificate Type / Grade / Number: INU 2.- 21/ `� 5
.�7
Signature:
Work. Phone #: )_ 9S5 3 36 0
Date: /, 3 / /7...
"1 certify that i 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 WaterPollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge/(BIT ORC)
Print Full Name: .�07 PS C1' fit wt s `r it
c� / 192q q 3
Certificate Type / Grade / Number: W ,2. $ 90 316 'I Work Phone #:
Signature: 7 yam,
"� Date:
"I certify that I agree to my 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 I3U ORC as set forth in 15A NCAC. 08G .0205 and failing to do so can result in
Disciplinary Actions by th.e Water Pollution Control System Operators Certification Commission."
(qzoan'
Mail or fax the original to: WPCSOCC, 1618 .Mali Service Center, .Raleigh, NC 27699-1618 Fax; 919.1307,6492
Mail or fax a copy to the
appropriate. Regional Wee:
Asheville
2090 US Hwy 70
Swannanoa 28778
Fart: 828.299.7043
Washington
943 Washington Sq lvMall
Washington 27889
Fax: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Mooresville
6 i.0 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Winston-Salem
585 Waughtown St
Winston-Salem 27107
Fax: [phone]
Raleigh
380013arrett Dr
Raleigh 27609
Fax: [phone]