NC0026921_ORC Designation Form_20150311

03/30/2015 08:59 9108589808 TOWN OF PARKTON
PAGE 01101
Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .0201
Permittee Owner/Officer Name:
Mailing Address: _ x
►A. oc Pc,Abi ./ v' t . V ilit 1cv ,
City: ec>t`IA-0 State: j\I CZip: 0 {'0�! l . - Phone to) 9,5
Email address: 1b 6iOC`��UG�� 4
Signature: 1211% a�' Date: 3/
Facility Name:
Permit #: ttiC,C)O ,CociR t
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Tine/Grade:
Biological WWTP
Physical/Chemical
Collection System
tntilft P/aa
Surface Irrigation
Land Application
Operator in Responsible Charge (ORC) j 1
Print Full Name: 1 i t+� o4 k C Ck d L t"`
Certificate Type / Gr, de / Number: V'J d, (DO0(c O . Work Phone #: (r'ItO) 411 ... (a.1(
Signature: ,A,+ ' / _ Date: 3 / 1 /15
"I certify than agree to my de . nation, as the Operator in Responsible Charge for the facility noted. I understand and will abide by the rules
and regulation 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 Pollution Control System Operators Certification Commission."
Back -Up Operator in Res onsibie Charge (BU ORC)
Print Full Narne: L
`� q� f -°
Certificate Type / Gxa:le / Number' S 7&i 1777, Work Phone #: t5/ d) a2?? $ I
Signature:
Date: 3/ 1 1( 1 5
"I certify that I agree tau my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules end regulations pertaining to the responsibilities of the 13U URC. as set forth in 15A, NCAC 08G .0205 and failing to do so can result in
Disciplinary fictions by the Water Pollution Control System Operators Certification Commission,"
Mail, fax or entail the
original to:
Mall or fax a copy to the
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Asheville
2090 US Hwy 70
Swazinanoa 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq Mall
Washington 27889
Fax: [phone]
Phone; 252.946.6481
Fayetteville
225 Greets St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
none: 910.433.3300
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]
Fax: [phone]
Mooresville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: 704! 663,6040
Phone: [phone]
Winston-Salem
585 Waughtown St
Winston. -Salem 2.7107
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: [phone]
Fho»e:2.t9.791.4200
Revised 0:3-2014