WQCS00268_WPCSOCC_20211029

Oct. 29. 2021 4:07PM
No. 0195 P. 2
WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM (WPCSOCC)
NCAC 15A 8G .0201
Permlttee Owner/Officer Name:
Press TAB to enter Information
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Email Address: C
Permlttee Signature:
Facility Name; C: p'� aG 1� o.�V r (( Permit # QC3 t 0 Co
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SUBMIT A SEPARATE FORM FOR EACH SYSTEM CLASSIFICATION; CS -IV
ORC - OPERATOR IN RESPONSIBLE CHARGE
Print Full Name: Thomas Johnson Jr
Certificate Type: CS
Certificate Grade: IV
Email Address: [e-mail]
Signature:,; Effective Date: 10 Wi'
"1 certify that I agree to my designation 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,"
Date: 05j'`Z !
Work Phone:
Certificate #:
910 459 6718
992243
Print Full Name: Percy Joseph Cephus
Certificate Type: CS
Email Address:
Signature:
"1 certify that I agree to my designatioh->?is 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 falling to do so can result in
Disciplinary Actions by the Water Pollution Control System Operators Certification Commission,"
BACKUP ORC
Certificate Grade: III
[e-mail]
Work Phone:
Certificate #:
910 581 2694
1003863
Mail, fax or email
ORIGINAL to:
Mail or Fax a COPY to:
WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618
Email: Fax: [phone]
Asheville
2090 US Hwy 70
Swannanoa, NC 28778
Fax: [phone]
Phone: [phone]
Washington
943 Washington Sq. Mall
Washington, NC 27889
Fax: [phone]
Phone: [phone]
Fayetteville
225 Green St., Suite 714
Fayetteville, NC 28301-5043
Fax; 910-486-0707
Phone: [phone]
Wilmington
127 Cardinal Dr.
Wilmington, NC 28405-2845
Fax: [phone]
Phone: [phone]
Effective Date: (cl2,
Mooresville
610 E. Center Ave., Suite 301
Mooresville, NC 28115
Fax; 704-663-6040
Phone: [phone]
Winston-Salem
45 W. Hanes Mill Rd.
Winston-Salem, NC 27105
Fax: [phone] Phone:
336-776-9800
Raleigh
3600 Barrett Dr.
Raleigh, NC 27609
Fax; 919-571-4718
Phone: [phone]
Revised 11/2020