NC0086550_ORC Designation Form_20130827

Aug 28 13 11:25a Fairmont
' 08/26/2012 15:6:. 91E43_8767 NC DENR
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W1. ter U°llution Control System Operator Designation Form
WFCSOCC
NCAC 1 SA. 8G .0201
Fermi ttee Owner/Officer Nante: -rQ'W iV 0 o"t
Mailing Address: P. C:) iFcs
AhCvZi ae Phone#: jf g 9,6. a
City: }—�•r !'frto�L :Mate; p:
Email address: � r' 2 s'14- A C iC-r E .s ev`+ r 1 • n 431-
IVZ. Date: `421/
Signature:
Facility Name:[ r"'l t'li
Facility '1) 2g/gradci
f3loloQical tuWT'P
Physical/Chemical
Collection 3ystt:m
Operator in Responsible C1:.9
Print Ful' Name:
Certificate Type / Grade / Nurr
f')
Signature, -- — /I`
"1 certify that.' agree tr my designtt.ii
and regulations pertaining to the rasp
Actions by the Water Pollution Cnntr
Nt W u i P Permit #: NC 00 ` .4.5.<0
}J:MjT A SEPARATE FORM FOR EACH TYPE SYSTEM!
..J Surface Irrigation
Land Application
(ORC)
1.:,,nn Ls' F-r-tee/k, iN1
to;r: " 11 I- `work Phone l#: (5/a) '7 -0 3
13/9a793 j' 7" /3
Date:
in as the 0perator in Responsible Charge for the facility hated. I. understand and will abide by the nllcs
nisibilitics of the 0RC as set forth in ISANCAC 0213 .0204 and failing to do so can result in Disciplinary
System Opetatora Certification Commission,"
Back -Up Operator in Rep
Print Full Name: _ PO z
Certificate Ty-p ihacle / Nun
Signature; Q(\N\-)k,
"1. certify thst I ogfee my.designoti
rules and regulations pertaining to Ih
Disciplinary Actions by the WaterPt
.Mail, fax nr email tie
original to:
Mail or fax a copy to the
appropriate Regional 0,,5rice:
i i:ble Charge (Bp' ORC)
tl' :r: •
%(Q00 Work Phone #:. /O) 14C1 —C1 06
Date;
:ri as a Beck-vp Operator in Responsible Charge for the facility [toted, I understand and will abide by the
;lsponsibilities of the BU ORC as set forth in 15A IYCAC (18U.0205 and failing to do so can result in
llul:inn Control System Operators Certification Commission."
t Y PCSOCC
1618 Mail Service Center, Raleigh, NC 27699.161E
sliteville
0i3OUSHwy 70
w mnance 28778
1 'a.;:: 828.299.71)43
Phone: 828,296,4500
N nshingcon
14:1 Washington 5q Mall
"Ntshington 27889
i; ix: 252.946 9215
tone:7.57..946.648i
Fttyettcvil le
225 Green St
Svitc 714
Fayetteville 28301.5043
Fax: [phone]
Phone: [phone]
Wilmington
127 Cardinal Dr
Wlimingron 28405-Z845
Fax: [phone]
Phone: [phone]
Fax: [phone]
Monrcaville
610 E Center Ave
Suite 301
Mooresville 28115
Fax: [phone]
Phone: [phone]
Winston-Salem
585 \Vaughtown St
winston-Salem 27107
Fax: 336./ 71.4631.
Phone: [phone]
Raleigh
3800 Barrels Dr
Raleigh 27609
Fax: 919.5.'71.47.18
Phone:919,791.4200
Reeked 0222.en