NC0086550_ORC Designation Form_20160112

Print Full Name:
Water Pollution Control System Operator Designation Form
wPCSOCC
NCAC 15A 8G .0201 WQROS
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FAYETTEVILLE REGIONAL OFFICE
littee Owner/Officer Name: / /D U%/(/ c� / � ,.
Mailing Address: - P r� [3 U)(g L/ �j
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City: Fci r (tY10 /1- State: A/C- Zip: 93c/0 - Phone #: (9/0)
Entail address: Fa- ( m o n -f - p
Signature: Pr1/41-., kdk/ -� Date: 1--12 - 2c$) (�
DEQ/DWR
JAN 14 2016
Facility Name: et-1 r l' Y ` o n-4— W 19 Permit #: (VC 000( KSO
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM! -
Facility Tvoe/Grade:
Biological WWTP
Physical/Chemical
Collection System
Surface Irrigation
Land Application
Operator in Responsible Charge (ORC)
get/; Iv/7. t.. //D / ___
Certificate Type /Grade 1 Number: lit)l 001 q1/ 4 Work Phone#: (9(0) 2 7.2 - 7 3
Signature:
Date: I — /2 —/ b
"I certify that I agree to my designation as the 1 . w .:fin Responsible Chargeforthe facility noted I understand and will abide by the rules
and regulations pertaining to the responsibilities ofthe ORC as set forth in I5A NCAC 08G .0204 and failing to do so can result in Disciplinary
Actions by the Water Poll Control System Operators Certification Commission:"
Back -Up Operator in nsible Charge (BU ORC)
Print Full Name: Di1 oily % ( -+—
Certificate Type / Grade / Number: ,0 W 15 1 /-/ Q Work Phone #: 6f 0 ) 2 %z — on)
Signature: ‘. certify that I : �, Date: J l0— J C,
9_ ' k. my designation as a Back-up Operator in Responsible Charge for the facility noted_ I understand and will abide by the
rules and regulations pertainbig to the responsibilities of the BU ORC as sex forth in 1SANCAC 08G .0205 and failing to do so can milt in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Mail, fax or email the
original to:
Mail or fax a copy to the
appropriate Regional Office:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phooe:828.296.4500
Washington
943 Washington Sri Mall
Washington 27889
Fax:[phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington mington 28405-2845
Fax: [phone]
Phone: [phone]
Fax: [phone]
Mooresville
610 E CenterAve
Suite301
Mooresville 28115
Fax: [phone]
Phone [phone]
Winston-Salem
585 Wanghtown St
Winston-Salem 27107
Fax: [phone]
Phone: [phone]
Raleigh
3800 BarrettDr
Raleigh 27609
Fax: [phone]
Phone:[phone]
Revised 02-2013

Facility Name: r�'t f Permit#: /)/ 00 k‘ ��o
Back -Up Operator in Responsible Charge (BU ORC)
Sea_l
Print Full Name:
Certificate .0 - / Grade / Number. W k' Cf 6 (��OG Work Phone #: (q7/J) 602,f- ' Ott/
SignDate: 112 —
"I certify that I agree to my designation as a Bark --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 BU ORC as set forth in 15A NCAC 08G .0205 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)
Print Full Name:
Certificate Type / Grade / Number: Work Phone #: ( )
Signature: Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility notedI understand and will abide by the
rules and regulations pertaining to the responsibilities ofthe BU ORC as set forth in 15A NCAC 08G .0205 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)
Print Full Name:
Certificate Type / Grade /Number. Work Phone #: ( )
Signature: Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining In the responsibilities of the BU ORC as set forth in 15A NCAC 08G .0205 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)
Print Full Name:
Certificate Type / Grade /Number: Work Phone #: ( )
Signature: Date:
"I certify that 1 agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertainingto the responib 'Edifies of the BU ORC as set forth in 15A NCAC 08G .0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Revised 02-2013