NC0037176_ORC_Designation_20220211

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
NCAC 15A 86 On
cos ro vok Aare FwM Water Quality Regional Operations
Asheville Regional Off icc
Facility Name: .Yi _ i Iw �Xtt 1 Aji ()IJ, Tfaw 4f 4( vafmh o NC003717$
F71<tllyfype: ww FardityGracle U Si1S"TAUPARATTFORM FOR fA NaAi$fACATK-YV
Petmitt0e OwAlr/Qtftlhf M8i4:,a�LAtn (.� l L
.__
£load f tEi%Illrj ( 3 `ro rv,
Date:
Permuttee signature:
Full Name: J NM ES Gi LEN SM j 1" Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: WW Certificate Grade: I i ® Certificate #: 1 P1 6
Signature: Effective Date:
"l ce that I agree to my designa on as the Operator in Responsible Charge for the facility noted. 1 understand and Will
abide 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."
Full Name: Vy &N I1 N Work Phone: [phone]
Certificate Type: WW Certificate Grade: I I ® Certificate #: 2-y G —4 4
Signature: Effective Date:
2- Z2
"I cell -that I agree to my desido6tion as a Back-up Operator in Responsible Charge for the facility noted. I understand and will
abide 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."
Full Name: S► 1 �N�ON J(�/� FPS Work Phone: [phone]
Certificate Type: WW Certificate Grade: I ® Certificate #: I (21 0 7-5 2-6
Signature: Effective Date: 2 - - ZZ
"I certify that/ 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: WKSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 i FAX: 919-71S-2726 [e-mail]
Mail or fax a COPY to: I Asheville-2090 US Hwy 70, Asheville, NC 28778 I FAX: [phone] I PH: 828-296-4500
Revised 312019

Facility Name: BON WORTH
Permit #: NC0037176
Page 2