NC0026921_ORC Designation Form_20051109

FROM :TOWN OF PARKTON FAX NO. :910 858 9808
NOV-03-2005 10:Z9AM FR011-.
OCC
NCAC 15e:0SGx .0201
General Information:
Permittee Owner/Officer Name:
Mailing Address:
City: p/ir- ,4 A Ad
Telephone Number; . (5/0 )
Signature ; 7 '
6t) AI Q -A
R v , cr 5 f
- State: /IG Zip:
Nov. 04 2005 09:45AM P2
T-580 P.002/002 F-681
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e?"5"g-3.3C0
imin! Datt: /1- 9-OS
Facility Information:.
Facility; C(- c,) 0 le r /C + r✓ CO.) -T P
Permit Number:
NC ' d' 0 Z 9 z ( County: e s
! SUBMIT A SEPARATE FORM FOR EACH TYPE OFSYSTEM !
IlutaLLTYR of Facility atig (1 - 4)
Wastewater Plant
Physical/Chemical
Collection System
I
Spray Irrigation
Land Application
Subsurface
Clan
EA
Operator in Responsible Charge:
PAW Name: Dh i /�� cl • ,5Lir'.
Certificate Type and Grade:. W - 3
e/7q-2329
Work Telephone: (ifv) - 5n' S-/Si Signature:
Back -tip Operator in kesponsible Charge:
Social Security # : q (/-j / e/t ��-
i
Certifcate #:
•
Print Name: 044t/ Y ( L, 1-,0 ,r4, Social Securi
.Certificate Type and Grad: t
Work Telephone: ( %/d) kG S -- s-)G y
•
Signature:
Mail RE Fax to: WPCSOCC
1618 Mall Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]
.1(12 -27-
: 'Certificate #: .2 l• '7 7 0 .,
4 c. - 0.,4 ),474117,-
FRP
pit
Revised 10/2000