NC0086550_ORC Designation Form_20031027

FROM ':PUBL I C WORK -TOWN -OF -FA I RMONT FAX NO. :910-628-9879 Dec. 01 2003 08:16AM P2
Water Pollution Control System. Designation Form
WPCSOCC
NCAC 15A:OSG..0201
C Er. feral Information:
Pe E nittee Owner/Officer Name: 7 WA) 0 P
I% ling Address: P, 0
T e phone Num
ip tere:
State: Al e Zip: cg 7C
Date: // 7/
P! 9 lity Information: L
P lity: 1CAi ev i civ..* LW A 14_41: er �� rrJe�'"#` P jAil±
Pa: nit Number: NC. 06.676,5,50 County: RO6 f'ory
`E! JDMIT A SEPARATE FORM FOR EACH TYPE OF SYSTEM !
be k (X) Tvio of Facility Clasp (1— 4)
tevrater Plant )C
Pli! :icai/Chemiical
C ai ection System
sill 1
Spray Irrigation
Land Application
Subsurface
Class
N/A
NjA
Op. rater in Responsible Charge:
Piii tName: 3okn ,
C!+'i iftcate Type and Grade: w VJ .3
Social Security* : , g,2 ?"Q8-f
V4 k Telephone: (pl0) OQc. Signature:
Certificate if: / S./540
rjA
13,L; :-Up Operator in Responsible Charge:
Pii! ; Name: [4E. A. P -EAz social security # : 242 - 3d - 4O
G er ificate Type and Grade: e t r r - ; = =;`� Certificate #:
W a k Telephone: (R I O) 2"7 z- O S Sign
Mai grFax to: ,WpCSOCC
1618 Mail Service Center
Raleigh, N.C. 27699-1618
Fax: [phone]