NCG590004_Other Agency Documents_20211102

Nov 01 21, 02:50p
p.1
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC /SA 8G .0201.
Press TAB to enter information
Perrnittee Owner/Officer Name: Brad Cornwell
Email Address:
Perrnittee Signature:
brad. cornwell@clevelandcou ntywater_corn
Facility Name: Cleveland County Water
SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION: PC -I
Permit #
NCG5900004
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Christopher Lee Elliott
Certificate Type: PC Q Certificate Grade: I
Email Address: [e-mail]
Signature:
Work Phone:
704-538-9033
Q Certificate #: 1009621
Effective Date: /0 - 1 -2/
"i 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 Water Pollution Control System Operators Certification Commission."
BACKUP ORC
Print Full Name: Garrett David Gilbert
Certificate Type: PC Certificate Grade: I
Email Address: garrett@a clevelandcountywater.cam
Signature:
Work Phone:
a Certificate #:
704-538-9033
1004605
Effective Date: /(7 - 4/- o2o2
certify that 1 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 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."
Act/tLe 60.4 A/Ott
Mail, fax or email WPCSOCC, 1618 Mail Service Center, Raleigh, INC 27699-1618
ORIGINAL to:
Mail or Fax a COPY to:
Email: [e-mail] Fax: [phone]
Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone:[phone]
Washington
943 Washington Sq. Mail
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green 5t., Suite 714
Fayetteville, NC 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: 91D-796-7215
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800
Raleigh
3800 Barrett Dr.
Raleigh, NC 27609
Fax: [phone]
Phone: [phone]
Revised 71,2020