NC0086550_ORC Designation Form_20140514

05/ 15/2014 13 : 05 Town of Fa i rmont pub I i c works (FAX) P , 001/004
Xwn of airmont
421 %out/i Main c9iireet
AO. aor 248
grairmant, i‘f6 28340
Rowel 410,1628.9766
Fax; /.10/ 628.6025
FACSIMILE TRANSMITTAL SHEET
TO; �A(
FROM: gea G`'^1,6,2.. ./v
COMPANY: DATE:
�,. ) ye-W tv PFA4e_
FAX NUMBER: PAGE 1 OF:
9.
PHONE NUMBER:
ok‘ aA)- CeAr6-146A)c
© URGENT ❑ PLEASE COMMENT 0 PLEASE REPLY 0 PLEASE RECYCLE
NOTES/COMMENTS:
NL Tit) - tA) TP
s�
IP YOU HAVE ANY PROBLEMS RECEIVING THIS FAX, PLEASE NOTIFY OUR OFPICO
IMMEDIATELY AND W1: WILL S Nt A REPLACEMENT OR MAKE OTHER ARRANGEMENTS.

05/ 15/2014 13: 05 Town of Fairmont pub I i c :works (FAX) P , 002/004
Water Pollution Control System Operator Designation Form
WPCSOCC
NCAC 15A 8G .002201
Perzlllttee Owner/Officer Name: / o u•' iv .. F t" ; / M b 4
Mailing Address: • e 0 QO g "t •
City: i Me)r►'t` State: p(.Zip: (kNo- : Phone#: CQ). fro " 7t5b
Email address: ►1' r1- ( •e I
Signature: V 4 Date: 22.50
Facilit
y Name: L,„,,+ aII���-rn�J �'y;�I-cn^ Permit#: kJi?GS660g7
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
jt•acility Tyne/Grade:
Biological WWTP
Physical/Chemical
Collection System
Surface Irrigation
Land Application
Operator In Responsible Charge (ORC)
Print Ful l Nance: __. j 5/%11 / 5 • . . •
Certifi I tirade /Number. rl 11.2-CD Work Phone #: (�!I• D ) —eV ‘ L�
Signature:, Qtytk Q Date: ; r/ fir / • • •
I Certify thrill agree to my designation as the Operator in Responsible Charge far the facility noted.1 understand and will abide by the roles
and regulations pertaining to the responsibilities of the ORC us set firth in ISA NCAC 080 .0204 and Siting to do so can result in Disciplinary
Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge (BU OR
Print Full Name: K€ u ; l Ay/ 6
Certificate Type / Grade / Number: 65,T q9 C/ 7'7d Work Phone #: (GJIO) 2Z - 0 8-3,
Signature:_,.._._.
Date:r�s" / .. .
"l certify that I. agree to my designation as a Back-up Opera t Responsible Charge for the facility noted. I understand and will abide by the
rules and reaulatione pertaining to the responsibilities ofthe U ORC as set forth in 15A NCAC 080.0205 and failing to do ao can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission"
Mal/, fax or «mall the WPCSOCC 1618 Mall Service Center, Raleigh, NC 27699-1618 Fax: [phone]
original to
Mali or fax a copy to the
apptoprlateReglorrai Office:
,K•
Asheville
2090 US Hwy 70
Swannenoa 28778
Fax: [phone]
Phouc 828.2964500
Washington
943 Washington Sq Mali
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Cowan St •
Suite 714 •
Fayetteville 28301-5043
Feu 910A860707
Phone: [phone]
Wilmington
127 Cardlnal Or
Wilmington 28405.2845
Fax: [phone]
Phone: [phone] -J
Mooresville
610E Center Ave
Suite 301
Mooresville 28115
Far: 704.663.6040
Phone:-704.663.1699
Winston-Salem
585 Waughtown St
Winston-Salem 27107
Fax: [phone]
Phone: [phone]
Raleigh
3800 Barrett Dr
Raleigh 27609
Fax: 919S71.4718
Phone:919 791,4200
Revlaed 02-2013

05/15/2014 13:05 Town of Fairmont pub I i c works (FAX) P , 003/004
Water Pollution Control System Operator Designation Form
WPCSoCC
NCAC 1SA 80.0201
•Faertllttee Owfer/Qillcer Name: /0 r.44✓ O F R . t • a,?
PO B oA 0,U r
Mailing Address: •
City: 'Ft.( !' Moil+' State: WC Zip: GI RNA Phone #: f / D) 6v2r "' / 7.sz
Email address:
Signature:
Fari+v$o(4-f-L . tic
� - Date: D ri. e J /
Facility Name: G..+ i &AC n k) G) TP Permit #: N e Qo Ed 6b
SUBMIT A SEPARATE FORM FOR EACH TYPE SYSTEM!
Facility Tyne/Grade:
Biological WWTP Surface Irrigation
Physical/Chemical Land Application
Collection System
Operator in Responsible Charge (ORC)
Print Full Name; t1 I n ay GPI'
Certificate Type/Grade/Number: k)bill /5it/ _ Work Phone#: f6110) ,2?,'�-dg"?3
Signature:
Date:
"1 certify that I agr t6my designations the Operator in Respodaible Charge for the fbclllty noted. I understand and will abide by the rules
and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 080.0204 and failing to do so can result in Dfseiplfnary
Actions by the Water Pollution Control System Operators Certification Commission."
Back -Up Operator in Responsible Charge�(� (BU ORC) ..//�..
Print Full Name:. Vev f` hJ I'T 1 �'i ,Z
Certificate Typo / G e / Number: q Work Phone #: ( ) J 27€ " 12 3_
Signature; Date: 5.:./�'- / lr
"I certify that I agree to my designation es a Back-up or in Responsible Charge for the theility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities o the BU ORC as set forth in 15A NCAC 080.0205 and failing to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission:"
!lull, fax or email lira
original lot
Mail orfax a copy to the
appropriate Regional Office:
WPCSOCC 1618 Mall Service Center, Raleigh, NC 27699-1618 Fox: 919.807.6492
»mil: �`� ���'�t�d'��r'd
Asheville
2090 US Hwy 70
Swannanoa 28778
Fax: [phone]
Phone: 828.296A500
Washington
943 Washington Sq Matt
Washington 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St
Suite 714
Fayetteville 28301-5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wilmington 28405-2845
Fax: [phone]
Phone: [phone]I5
Mooresville
6I0 8 Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Wlnston•Salem
585 Waughtown St
Winston-Salem 27107
Fax: [phone]
Phone: [phone]
itsleigh
3800 Barrett Dr
Raleigh 27609
Fax: 919.571A7I8
Phone:[phone]
Revised 02-2013

05/ 15/2014 13:06 Town of Fairmont pub I i c works (FAX) P . 004/004 ;
Facility Name:
I
I
fr L1+ i L TF'
permit#: 6,0,46 ,(--6
Back -Up Operator in Responsible Charge (BUORC)
Print Full Name:. �fi r)N 1 t° 5
Certificate Grade / Number: 1) kJ f ' 6 02Dg.'
Signature;. Q¢t
Work phone #: (t3/0) / o26-"did9
Date:
"I certify that I agree to my designation as a Backup 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 #: f )
Signature: Date:
"I certify that I agree to my designation as a Backup Operator in Responsible Charge for the facility noted. I understand and will abide by the
rules and regulations pertaining to the responsibilities ofthe BU ORC as set forth in iSA 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 la Responsible Charge (BU ORC)
Print Full Name:
Certificate Type / Grade / Number: Work Phone #: (
Signature: 0 Date:
•
"1 certify that I agree to my designation as a Backup Operator in Responsible Charge for the iiicility noted, I understand and will abide by the
rules and regulations pertaining to the responsibilities ofthe BU ORC as set forth in 1SA NCAC 080.0205 and lhlling to do so can result in
Disciplinary Actions by the Water Polludon Control System Operators Certification Commission,"
Back -Up Operator in Responsible Charge (BU ORC)
Print Full Name;
Certificate Type / Grade / Number: , Work phone #: ( _- )
Signature: Date:
certlty that 1 agree to my designation as a Back-up Operator in Responsible Charge for the fhcillty noted. 1 understand and will abide by the
rules and regulations pertaining to the responsibilities ofthe BU ORC as set fbrth in 15A NCAC 080.0205 and failing to do so can result in
Dlselplinaty Actions by the Water Pollution Control System Operators Certification Commission."
Revised 02-2013