NC0020486_ORC_Designation_20220211

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
NCAC 15A 8G .0201
TAB to Navigate Aorm
Iracility Name. NORTH MILLS RIVER RECREATIONAL AREA
Permit # NCO020486
Facility Type: WW Facility Grade: 11 SUBMITAStiAWTiEFORMFOR EACH CLASStFICA770N
Permittee Owner/Officer Name: KEN STAMPS
Email Address: ken.
Permittee Signature:" I
Date:
Full Name: J VT1N I J Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: WW __ Certificate Grade: 11Certificate #: 2-H C)�:j-4
Signature: Effective Date:
"I certif at l agree to my desi at'
as the Operator in Responsible Charge for the facility noted. l understand and will
abide b he rules and regulations p as
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:yTT IV �0 N �1 f�MES Work Phone: [phone]
Certificate Type: WW _ Certificate Grade: 0 Certificate #:_ I 252J6
Signature: _6 Z Effective Date:
"I certify that l agree to my designation as 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 failing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission. "
Full Name:y� F S' LEN SM VVH Work Phone: [phone]
Certificate Type: WW Certificate Grade: I )
Certificate #: � l 3�.�
Signature:
Effective Date:
:ab,idebytherule
ertify that I a ree to my designation as a Backup Operator in Responsible Charge for the facility noted. I understand andwill
and regulations pertaining to the responsibilities of the ORC as set forth in 1SA NCAC 08G .0204 and failing to do
so can result in D ciplinary Actions by the Water Pollution Control System Operators Certification Commission." _
_ 1II Mail, fax or email ORIGINAL to: WPCSOCC, 1618 Mail Service Center, Raleigh, NC 27699-1618 FAX: 919 7 �276�!rc ad i p
_ , , I min@nc en .
Mail or fax a COPY to: Asheville-2090 US Hwy 70, Asheville, NC 28778 1 FAX: 828_299-7043 1 PH: 828 f 96-45p0i
Revised 312019
Water Quality Regional Operations
Asheville Regional Office

Page 2
Facility Name: NORTH MILLS RIVER REC AREA Permit #: NC0020486