NC0068799_ORC_Designation_20220211

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
NCAC 15A 8G .0201
TAB to Navigate Form
Facility Name: GREYSTONE Water QualiWeVofia! !` NCO068799
As evillP Regio
Facility Type: WW Facility Grade: II SUBMIT SEPARATE FORM FOR EACH CLASSIFICATION
Permittee Owner/Officer Name: GREYSTONE ENTERPRISES INC
Email Address: GREYSTONEMGT OL.COM
Permittee Signature:
Date:
Full Name: j ftN\t_z�) �51 LZ'N 't_JM I Vti Work Phone: _ 828-697-0063
Email Address: [e-mail]
Certificate Type: WW Certificate Grade: I I _ ® Certificate #:
Signature: Effective Date:
Aby
agree to my designation as the Operator in ResponsibleCharge for the facility noted. 1 understand and will
les and regulations pertaining to the responsibilities of the ORC as set forth in 15A NCAC 0BG .0204 and
failing to do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission."
Full Name: M ES Work Phone: [phone]
Certificate Type: WW _ Certificate Grade: I I ® Certificate #:_2_LjG j y
Signature: Effective Date: 2- '" `ZZ
4abideby
agree to my designot as a Back-up Operator in Responsible Charge for the facility noted. 1 understand and will
ules 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."
Full Name: V �fl\N Nam A V—S Work Phone: [phone]
Certificate Type: WW Certificate Grade: I I Certificate #:
Signature: - C _Effective Date:
"I certify that I agree to my designation as a Back-up 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."
Mail, fax or email ORIGINAL to: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 1 FAX: [phone] [e-mail]
Mail or fax a COPY to
Asheville-2090 US Hwy 70, Asheville, NC 28778 1 FAX: [phone] PH: 828-296-4500
Revised 312019

Facility Name: GREYSTONE
Permit #: NC0068799
Page 2