NC0004464_ORC Designation_20220211

WATER POLLUTION CONTROL SYSTEM OPERATOR DESIGNATION FORM
NCAC 15A 8G .0201
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Facility Name: WOODLAND MILLS
Facility Type:
Permit # NC0004464
yyyy Facility Grade: II SUBMIT SEPARATE FORM FOR EACH �L,g55/F/CAT/ON
Permittee Owner/Officer Name: MARCHE PITTMAN
Email Address: mpittman
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Permittee Signature: � Irnl �{
na+o• i��-�%
Work Phone: [phone]
Email Address: [e-mail]
Certificate Type: WW Certificate Grade: I I
Certificate #: 10 11 3 —+ (�
Signature:
:abide
certify thEffective Date:
at l a ee to my designation as the Operator in Responsible Charge for the facility noted. l understand and will
by the rule 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: JVftN IT 34N- 1 FS Work Phone: [phone]
Certificate Type: WW Certificate Grade: I I t l f I
Certificate #: Z
Signature:
to
"I certi t at I agree to my desi n Effective Date:
nsible
abide b he rules and regulations pertaini ctheresponsibilities rin erator in eof othe ORC asset forge or the rth inacility noted. /understand 15A NCAC 08G .0204 andfailing to
do so can result in Disciplinary Actions by the Water Pollution Control System Operators Certification Commission. "
Full Name: �� �t__�( () l v 1
Work Phone: [phone]
Certificate Type: WW �
_ Certificate Grade: I ( � �
--- Certificate #:
Signature: _
Effective Datej—"
l certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. l 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 oilin to d�
so can result in Disciplinary Actions by the Water Pollution Control System Operators Certificat7),
`C riamissio'n 11
Mail, fax or email ORIGINAL to: WPCSOCC, 1618 Mail -Service Center, Raleigh, NC 27699-1618 I FAX: 919- �,��..
_ _ [e-mail]
Mail or fax a COPY to: Asheville-2090 US Hwy 70, Asheville, NC 28778 I FAX: [phone] PH: 828-296-4500 _' O
'dater (duality RegionaWf�r .ivs
Asheville Regional Office

Facility Name: WOODLAND MILLS
Full Name: Davis James
Certificate Type: WW Certificate Grade: II
Permit #:
NC0004464
Work Phone: [phone]
Certificate #:_ 997463
Page 2
Signature: — 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."
Signature:
Effective Date:
"I certify that I agree to my designation as a Back-up Operator in Responsible Charge for the facility noted. l 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."